Healthcare Provider Details

I. General information

NPI: 1154328573
Provider Name (Legal Business Name): SONYA C CAMILLI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 ATKINSON DR
LUDINGTON MI
49431-1953
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 231-843-3487
  • Fax: 231-843-4525
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601004803
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: