Healthcare Provider Details

I. General information

NPI: 1831600824
Provider Name (Legal Business Name): GILLIAN K CUPP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 W KALAMAZOO AVE
KALAMAZOO MI
49007-3334
US

IV. Provider business mailing address

418 W KALAMAZOO AVE
KALAMAZOO MI
49007-3334
US

V. Phone/Fax

Practice location:
  • Phone: 269-553-8019
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number4704320763
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: