1205260718 NPI number — AZSHA RENEE WINN FNP

Table of content: AZSHA RENEE WINN FNP (NPI 1205260718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205260718 NPI number — AZSHA RENEE WINN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINN
Provider First Name:
AZSHA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTHEWS
Provider Other First Name:
AZSHA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205260718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28650 SUNSET BLVD W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHRUP VILLAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076-7020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13667 EUREKA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195-1332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-530-6777
Provider Business Practice Location Address Fax Number:
734-468-1156
Provider Enumeration Date:
09/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  672570-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704310223 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 672570-1 . This is a "RN LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4704310223 . This is a "MICHIGAN NP LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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