Healthcare Provider Details

I. General information

NPI: 1003541707
Provider Name (Legal Business Name): MICKIE TINGLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7014 DEWEESE RD
JACKSON MI
49201-7515
US

IV. Provider business mailing address

890 N 10TH ST
KALAMAZOO MI
49009-6192
US

V. Phone/Fax

Practice location:
  • Phone: 269-716-6970
  • Fax:
Mailing address:
  • Phone: 269-427-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704225660
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: