Healthcare Provider Details

I. General information

NPI: 1790162444
Provider Name (Legal Business Name): DEBORAH FAE ELDRIDGE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 E M 20
HESPERIA MI
49421-9082
US

IV. Provider business mailing address

3431 E M 20
HESPERIA MI
49421-9082
US

V. Phone/Fax

Practice location:
  • Phone: 231-861-5440
  • Fax:
Mailing address:
  • Phone: 231-861-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704295024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: