Healthcare Provider Details

I. General information

NPI: 1306432059
Provider Name (Legal Business Name): ASHLEY MARIE GOSS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 STIRLING DR
INTERLOCHEN MI
49643-9264
US

IV. Provider business mailing address

6227 FRANKFORT HWY
BENZONIA MI
49616-8632
US

V. Phone/Fax

Practice location:
  • Phone: 231-275-7965
  • Fax:
Mailing address:
  • Phone: 231-882-9661
  • Fax: 231-882-9616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704297822
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: