Basic Information
| Provider Information | |||||||||
| NPI: | 1114929338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARBUCKLE | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | RN, NPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16001 W 9 MILE RD | ||||||||
| Address2: | DEPT OF NEONATOLOGY | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484653144 | ||||||||
| FaxNumber: | 2484653146 | ||||||||
| Practice Location | |||||||||
| Address1: | 16001 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WN0002X | 4704076259 | MI | N | Nursing Service Providers | Registered Nurse | Neonatal Intensive Care | 364SN0000X | 4704076259 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Neonatal | 363LN0000X | 4704076259 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0005X | 4704076259 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 439455810 | 05 | MI | MEDICAID |