Basic Information
| Provider Information | |||||||||
| NPI: | 1346631470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | LACRETIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FISHER | ||||||||
| OtherFirstName: | LUCRETIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | SUITE 400-CREDENTIALING DEPARTMENT | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139933434 | ||||||||
| FaxNumber: | 3139933421 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CHRYSLER SERVICE DR | ||||||||
| Address2: | TOLAN PARK | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139933434 | ||||||||
| FaxNumber: | 3139933421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2015 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704281509 | MI | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 4704281509 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3434247 | 05 | MI | MEDICAID |