Healthcare Provider Details

I. General information

NPI: 1699023259
Provider Name (Legal Business Name): THERESE L. BOGGIANO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESE KUBIAK

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12265 JAMES ST
HOLLAND MI
49424-8613
US

IV. Provider business mailing address

131 W SEAWAY DR STE 200
NORTON SHORES MI
49444-3761
US

V. Phone/Fax

Practice location:
  • Phone: 616-494-5698
  • Fax:
Mailing address:
  • Phone: 616-494-5698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number4704278126
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704278126
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: