1639688393 NPI number — MS. COLETTE MARIE ICASIANO CLAYTON M.S., P.A.-C

Table of content: MS. COLETTE MARIE ICASIANO CLAYTON M.S., P.A.-C (NPI 1639688393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639688393 NPI number — MS. COLETTE MARIE ICASIANO CLAYTON M.S., P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAYTON
Provider First Name:
COLETTE
Provider Middle Name:
MARIE ICASIANO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639688393
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47045 ROSEMARY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACOMB
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48044-2582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-744-5185
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39621 GARFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-4302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-226-5555
Provider Business Practice Location Address Fax Number:
586-226-4441
Provider Enumeration Date:
09/26/2017

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: 363A00000X , with the licence number:  5601008354 , 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)





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