Healthcare Provider Details

I. General information

NPI: 1154707743
Provider Name (Legal Business Name): KATIE M ALFREDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 E SHERMAN BLVD
MUSKEGON MI
49444-1879
US

IV. Provider business mailing address

216 TERRA CIR
MUSKEGON MI
49445-2766
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-3648
  • Fax: 231-672-3838
Mailing address:
  • Phone: 231-672-3648
  • Fax: 231-672-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704283005
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704283005
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: