Provider Demographics
NPI:1366102691
Name:GAVIN, NELVITA
Entity type:Individual
Prefix:
First Name:NELVITA
Middle Name:
Last Name:GAVIN
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 1:19510 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3234
Mailing Address - Country:US
Mailing Address - Phone:248-760-8404
Mailing Address - Fax:
Practice Address - Street 1:19510 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-3234
Practice Address - Country:US
Practice Address - Phone:248-760-8404
Practice Address - Fax:248-796-7880
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110439164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse