Provider Demographics
NPI:1588927883
Name:WADE, LORETTA NADINE (RN)
Entity type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:NADINE
Last Name:WADE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17526 SHAFTSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3544
Mailing Address - Country:US
Mailing Address - Phone:313-255-0418
Mailing Address - Fax:
Practice Address - Street 1:26180 WEST OUTER DRIVE
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146
Practice Address - Country:US
Practice Address - Phone:313-389-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704096674163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse