MEDICARE: MARK GEORGE MYNSBERGE RN

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	163W00000X	Registered Nurse	4704202716	MI

General Provider Information

NPI Number	:	1770242273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK GEORGE MYNSBERGE RN

Provider Business Mailing Address
First Line	:	1019 SPIREA
Second Line	:
City	:	HOWELL
State	:	MI
Zip	:	48843-6822
Country	:	US
Telephone Number	:	810-938-8367
Fax Number	:

Provider Business Practice Location Address
First Line	:	1002 E GRAND RIVER AVE
Second Line	:
City	:	HOWELL
State	:	MI
Zip	:	48843-1718
Country	:	US
Telephone Number	:	517-546-8701
Fax Number	:

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

Provider Enumeration Date	:	12/12/2021
Last Update Date	:	12/12/2021

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