Healthcare Provider Details

I. General information

NPI: 1790054351
Provider Name (Legal Business Name): CHARLOTTE R CLOSSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E MANSION ST STE 1E
MARSHALL MI
49068-1167
US

IV. Provider business mailing address

215 E. MANSON STREET SUITE 1E
MARSHALL MI
49068-1167
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-3938
  • Fax: 269-781-8364
Mailing address:
  • Phone: 269-781-3938
  • Fax: 269-781-8364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704102830
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: