Healthcare Provider Details

I. General information

NPI: 1073626057
Provider Name (Legal Business Name): BETH SIPPLE JANICK CNS NO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4572 S HAGADORN RD SUITE 3B
EAST LANSING MI
48823-5385
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-410-0729
  • Fax: 517-999-3317
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number4704194601
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: