Healthcare Provider Details

I. General information

NPI: 1619121118
Provider Name (Legal Business Name): HILARY K MARINE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE STE 200
GRAND RAPIDS MI
49503-2556
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 133
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704242489
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: