Provider Demographics
NPI:1386114742
Name:POOKRUM, MAVIS GAIL
Entity type:Individual
Prefix:MS
First Name:MAVIS
Middle Name:GAIL
Last Name:POOKRUM
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 1:21732 COLONY PARK CIRCLE #105
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:313-283-7838
Mailing Address - Fax:
Practice Address - Street 1:21732 COLONY PARK CIRCLE #105
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:313-283-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant