Healthcare Provider Details

I. General information

NPI: 1730288598
Provider Name (Legal Business Name): VICKI LYNN HUFFMAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKI LYNN WARNER PAC

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 44TH ST STE A
GRAND RAPIDS MI
49548
US

IV. Provider business mailing address

1841 SEVENTH NW
GRAND RAPIDS MI
49504
US

V. Phone/Fax

Practice location:
  • Phone: 616-531-9750
  • Fax: 616-531-9710
Mailing address:
  • Phone: 616-453-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001973
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: