Provider Demographics
NPI:1548796964
Name:PALAIYAN, AMUDHA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:AMUDHA
Middle Name:
Last Name:PALAIYAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WILLIAM CARLS DR # 100
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-2201
Mailing Address - Country:US
Mailing Address - Phone:248-937-4764
Mailing Address - Fax:248-937-4729
Practice Address - Street 1:1 WILLIAM CARLS DR # 100
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-2201
Practice Address - Country:US
Practice Address - Phone:248-937-4764
Practice Address - Fax:248-937-4729
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470258315363LP2300X
MI4704258315363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care