Provider Demographics
NPI:1669400792
Name:WEATHERLY, JANET (CNM)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15717 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2101
Mailing Address - Country:US
Mailing Address - Phone:586-285-3838
Mailing Address - Fax:586-285-3994
Practice Address - Street 1:15717 15 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2101
Practice Address - Country:US
Practice Address - Phone:586-285-3838
Practice Address - Fax:586-285-3994
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI141191367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P13150001Medicare ID - Type Unspecified
MIS67628Medicare UPIN