Provider Demographics
NPI:1285281931
Name:WIGGLE, RAYLENE MARIE (RN)
Entity type:Individual
Prefix:MS
First Name:RAYLENE
Middle Name:MARIE
Last Name:WIGGLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:RAYLENE
Other - Middle Name:MARIE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2705 ORMOND RD
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48383-1870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24230 KARIM BLVD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2960
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704323843163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty