Provider Demographics
NPI:1568264273
Name:DANDRIDGE, MARLISA (LPN)
Entity type:Individual
Prefix:
First Name:MARLISA
Middle Name:
Last Name:DANDRIDGE
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6821 MEDBURY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48211-3317
Mailing Address - Country:US
Mailing Address - Phone:313-922-2222
Mailing Address - Fax:866-287-5710
Practice Address - Street 1:6821 MEDBURY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-3317
Practice Address - Country:US
Practice Address - Phone:313-922-2222
Practice Address - Fax:866-287-5710
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703122824164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse