Healthcare Provider Details

I. General information

NPI: 1699328393
Provider Name (Legal Business Name): MARY TIBBE MSN RN CCRN-K AGCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

18901 W KIMBALL RD
PIERSON MI
49339-9605
US

V. Phone/Fax

Practice location:
  • Phone: 616-520-1135
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number4704270663
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: