Provider Demographics
NPI:1013268903
Name:PURDLE, TICONNA D (NP)
Entity Type:Individual
Prefix:
First Name:TICONNA
Middle Name:D
Last Name:PURDLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21333 HAGGERTY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5510
Mailing Address - Country:US
Mailing Address - Phone:248-662-0250
Mailing Address - Fax:248-662-9844
Practice Address - Street 1:7325 S EXCHANGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3407
Practice Address - Country:US
Practice Address - Phone:773-731-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009555363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily