Healthcare Provider Details

I. General information

NPI: 1992440812
Provider Name (Legal Business Name): AMY LYNN BUPP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E CROSSTOWN PKWY
KALAMAZOO MI
49001-2501
US

IV. Provider business mailing address

615 E CROSSTOWN PKWY
KALAMAZOO MI
49001-2501
US

V. Phone/Fax

Practice location:
  • Phone: 269-553-7037
  • Fax: 269-382-0019
Mailing address:
  • Phone: 269-553-7037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704280750
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: