Provider Demographics
NPI:1982373411
Name:JUTILA-WALDRON, DEANDRA
Entity Type:Individual
Prefix:
First Name:DEANDRA
Middle Name:
Last Name:JUTILA-WALDRON
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 1:36986 DIVISION RD APT 2
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MI
Mailing Address - Zip Code:48062-5417
Mailing Address - Country:US
Mailing Address - Phone:586-873-4709
Mailing Address - Fax:
Practice Address - Street 1:215 NORTH AVE # 200
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1716
Practice Address - Country:US
Practice Address - Phone:586-307-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide