Provider Demographics
NPI:1326874199
Name:DEPRIEST, MICHELLE LAURYN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LAURYN
Last Name:DEPRIEST
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 1:51170 FORD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4602
Mailing Address - Country:US
Mailing Address - Phone:734-260-5766
Mailing Address - Fax:
Practice Address - Street 1:51170 FORD RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4602
Practice Address - Country:US
Practice Address - Phone:734-260-5766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant