Provider Demographics
NPI:1972005510
Name:HARRISON, PATTI
Entity Type:Individual
Prefix:MRS
First Name:PATTI
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 FASHION SQUARE BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1291
Mailing Address - Country:US
Mailing Address - Phone:989-799-0410
Mailing Address - Fax:
Practice Address - Street 1:3995 FASHION SQUARE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1291
Practice Address - Country:US
Practice Address - Phone:989-799-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703083641164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid