Healthcare Provider Details

I. General information

NPI: 1922296730
Provider Name (Legal Business Name): LISA ANN MERVENNE O.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4696
US

IV. Provider business mailing address

4075 SILVERGRASS DR NE
GRAND RAPIDS MI
49525-9552
US

V. Phone/Fax

Practice location:
  • Phone: 616-735-6050
  • Fax:
Mailing address:
  • Phone: 616-447-0102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5201000452
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: