Basic Information
| Provider Information | |||||||||
| NPI: | 1063084242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACK | ||||||||
| FirstName: | SIEIRA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25844 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483742171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894000605 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25639 FORD RD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481274817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132773293 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2021 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | 4704323324 | MI | Y | Nursing Service Providers | Registered Nurse | Medical-Surgical |
No ID Information.