Provider Demographics
NPI:1972518678
Name:LONTORFOS, DEBRA JEAN (NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:LONTORFOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:JEAN
Other - Last Name:KOWALSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:FSC
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:248-423-2454
Mailing Address - Fax:248-423-2576
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:FSC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-423-2454
Practice Address - Fax:248-423-2576
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704154705363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4578733Medicaid