Provider Demographics
NPI:1063972800
Name:TOLBERT, AMICAH DESIRAY
Entity type:Individual
Prefix:
First Name:AMICAH
Middle Name:DESIRAY
Last Name:TOLBERT
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 1:17608 GATEWAY CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4718
Mailing Address - Country:US
Mailing Address - Phone:248-238-9195
Mailing Address - Fax:
Practice Address - Street 1:17608 GATEWAY CIR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4718
Practice Address - Country:US
Practice Address - Phone:248-238-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703112807164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse