Basic Information
| Provider Information | |||||||||
| NPI: | 1073535308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKILLOP | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEARL | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22255 GREENFIELD RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488492710 | ||||||||
| FaxNumber: | 2488494024 | ||||||||
| Practice Location | |||||||||
| Address1: | 22255 GREENFIELD RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488492710 | ||||||||
| FaxNumber: | 2488494024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704140266 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163WD0400X | 4704140266 | MI | N | Nursing Service Providers | Registered Nurse | Diabetes Educator | 363LA2200X | 4704140266 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 110F324280 | 01 | MI | BCBS GROUP# | OTHER |