Provider Demographics
NPI:1740167675
Name:DUFFIE, MILDRED JILLENE
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:JILLENE
Last Name:DUFFIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12545 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-1819
Mailing Address - Country:US
Mailing Address - Phone:313-600-3495
Mailing Address - Fax:
Practice Address - Street 1:12545 WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-1819
Practice Address - Country:US
Practice Address - Phone:313-600-3495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker