Healthcare Provider Details

I. General information

NPI: 1821471558
Provider Name (Legal Business Name): ELIZABETH ROUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HAZEN ST STE L3
PAW PAW MI
49079-1040
US

IV. Provider business mailing address

2710 MOUNT OLIVET RD
KALAMAZOO MI
49004-1612
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-1595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704280223
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704280223
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: