MEDICARE: JUDY BIVINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703054205	MI

General Provider Information

NPI Number	:	1164819561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDY BIVINS

Provider Business Mailing Address
First Line	:	10515 HAYES RD
Second Line	:
City	:	CLARKLAKE
State	:	MI
Zip	:	49234-9748
Country	:	US
Telephone Number	:	517-592-3038
Fax Number	:

Provider Business Practice Location Address
First Line	:	10515 HAYES RD
Second Line	:
City	:	CLARKLAKE
State	:	MI
Zip	:	49234-9748
Country	:	US
Telephone Number	:	517-592-3038
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	04/23/2015

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Directions to “ JUDY BIVINS ” Practice Location

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