Healthcare Provider Details

I. General information

NPI: 1922042829
Provider Name (Legal Business Name): CAROLYN D BAKER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W GREEN ST
HASTINGS MI
49058-1710
US

IV. Provider business mailing address

100 MICHIGAN STREET NE, MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3139
  • Fax: 616-391-3044
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704151642
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: