Provider Demographics
NPI:1336771427
Name:HUTCHINSON, WANDA R
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:R
Last Name:HUTCHINSON
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 1:275 MERTON RD APT 308
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-2292
Mailing Address - Country:US
Mailing Address - Phone:313-896-8514
Mailing Address - Fax:
Practice Address - Street 1:275 MERTON RD APT 308
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2292
Practice Address - Country:US
Practice Address - Phone:313-896-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
MI83-2648701374U00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI83-2648701Medicaid