Provider Demographics
NPI:1144677915
Name:BUFORD, SHERITTA MARIE (MT)
Entity type:Individual
Prefix:
First Name:SHERITTA
Middle Name:MARIE
Last Name:BUFORD
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13960 METTETAL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-1747
Mailing Address - Country:US
Mailing Address - Phone:313-293-1054
Mailing Address - Fax:866-466-3087
Practice Address - Street 1:21331 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3265
Practice Address - Country:US
Practice Address - Phone:313-293-1054
Practice Address - Fax:866-466-3087
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist