Provider Demographics
NPI:1871177527
Name:SUBER, AMONIQUE ELIZABETH (LPN)
Entity type:Individual
Prefix:
First Name:AMONIQUE
Middle Name:ELIZABETH
Last Name:SUBER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-0226
Mailing Address - Country:US
Mailing Address - Phone:586-444-9472
Mailing Address - Fax:
Practice Address - Street 1:19130 APPLETON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-5612
Practice Address - Country:US
Practice Address - Phone:586-444-9472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703120460164W00000X
MIR2L6G7J3246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No164W00000XNursing Service ProvidersLicensed Practical Nurse