Healthcare Provider Details

I. General information

NPI: 1700591005
Provider Name (Legal Business Name): CONNIE M BOOMS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15774 STATE ST
HILLMAN MI
49746-7961
US

IV. Provider business mailing address

PO BOX 427
HILLMAN MI
49746-0427
US

V. Phone/Fax

Practice location:
  • Phone: 989-742-4583
  • Fax: 989-318-4606
Mailing address:
  • Phone: 989-354-2197
  • Fax: 989-354-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704298561
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: