Provider Demographics
NPI:1649880329
Name:FORD, DEDRA DELANE (NP-C)
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:DELANE
Last Name:FORD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:DEDRA
Other - Middle Name:
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6210
Mailing Address - Country:US
Mailing Address - Phone:248-849-7400
Mailing Address - Fax:248-849-7401
Practice Address - Street 1:22250 PROVIDENCE DR STE 202
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6210
Practice Address - Country:US
Practice Address - Phone:248-849-7400
Practice Address - Fax:248-849-7401
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily