Healthcare Provider Details

I. General information

NPI: 1568030880
Provider Name (Legal Business Name): KATINA ANN PULOS KUERTH DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S SHERIDAN DR
MUSKEGON MI
49442-6240
US

IV. Provider business mailing address

1884 DUFF RD
TWIN LAKE MI
49457-9082
US

V. Phone/Fax

Practice location:
  • Phone: 231-329-3994
  • Fax:
Mailing address:
  • Phone: 231-329-3994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704252042
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704252042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: