Healthcare Provider Details

I. General information

NPI: 1013786128
Provider Name (Legal Business Name): ELIZABETH REVERE MCMAHAN AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2023
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9450 S SAGINAW RD STE E
GRAND BLANC MI
48439-8206
US

IV. Provider business mailing address

9450 S SAGINAW RD STE E
GRAND BLANC MI
48439-8206
US

V. Phone/Fax

Practice location:
  • Phone: 810-695-4000
  • Fax:
Mailing address:
  • Phone: 810-695-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704318459
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: