Provider Demographics
NPI:1740461185
Name:MIROVSKY, RENEE ANNETTE (NP)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:ANNETTE
Last Name:MIROVSKY
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 1:4576 W WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4077
Mailing Address - Country:US
Mailing Address - Phone:248-673-6633
Mailing Address - Fax:248-673-6677
Practice Address - Street 1:4576 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4077
Practice Address - Country:US
Practice Address - Phone:248-673-6633
Practice Address - Fax:248-673-6677
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195563363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health