Provider Demographics
NPI:1245638071
Name:LOUGHEAD, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:LOUGHEAD
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 1:249 BROOKWOOD DR
Mailing Address - Street 2:UNIT 7
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1847
Mailing Address - Country:US
Mailing Address - Phone:248-756-8952
Mailing Address - Fax:
Practice Address - Street 1:249 BROOKWOOD DR
Practice Address - Street 2:UNIT 7
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1847
Practice Address - Country:US
Practice Address - Phone:248-756-8952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704305444163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse