Provider Demographics
NPI:1750765863
Name:BOUSQUETTE-TROTTER, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOUSQUETTE-TROTTER
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 1:20093 GILL RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1119
Mailing Address - Country:US
Mailing Address - Phone:734-546-2347
Mailing Address - Fax:
Practice Address - Street 1:20093 GILL RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1119
Practice Address - Country:US
Practice Address - Phone:734-546-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704196161363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health