Healthcare Provider Details

I. General information

NPI: 1669479234
Provider Name (Legal Business Name): SUZANNE BENTLEY KIRK BS, MS, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1198 N WEST AVE
JACKSON MI
49202-2047
US

IV. Provider business mailing address

810 BRIARCLIFF RD
JACKSON MI
49203-3857
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1200
  • Fax: 517-796-4547
Mailing address:
  • Phone: 517-414-4845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704211265
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: