Healthcare Provider Details

I. General information

NPI: 1326519950
Provider Name (Legal Business Name): MELISSA MARIE OUTMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 E BELTLINE CT NE
GRAND RAPIDS MI
49525-9480
US

IV. Provider business mailing address

14215 28TH ST
LOWELL MI
49331-8658
US

V. Phone/Fax

Practice location:
  • Phone: 616-226-2669
  • Fax:
Mailing address:
  • Phone: 301-356-4713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704284313
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: