Healthcare Provider Details

I. General information

NPI: 1023251618
Provider Name (Legal Business Name): MARILYN GAIL HUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2009
Last Update Date: 04/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 LYNNE LN NW
GRAND RAPIDS MI
49504-6029
US

IV. Provider business mailing address

1912 LYNNE LN NW
GRAND RAPIDS MI
49504-6029
US

V. Phone/Fax

Practice location:
  • Phone: 616-735-1592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703086473
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: