Basic Information
| Provider Information | |||||||||
| NPI: | 1326474248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ONUFRAK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ANP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIKURA | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3350 GRATIOT BLVD | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480402121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103644000 | ||||||||
| FaxNumber: | 8103645995 | ||||||||
| Practice Location | |||||||||
| Address1: | 3350 GRATIOT BLVD | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480402121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103644000 | ||||||||
| FaxNumber: | 8103645995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 01/29/2015 | ||||||||
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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 | 363LA2200X | 4704266390 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1326474248 | 05 | MI | MEDICAID |