Healthcare Provider Details

I. General information

NPI: 1720429566
Provider Name (Legal Business Name): CAROL BUENTELLO NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MAGNETIC ST
MARQUETTE MI
49855-2700
US

IV. Provider business mailing address

374 N NOREN LAKE DR
GWINN MI
49841-9062
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3406
  • Fax:
Mailing address:
  • Phone: 906-360-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number4704222255
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10078
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: