Healthcare Provider Details

I. General information

NPI: 1245920669
Provider Name (Legal Business Name): PAOLA PAQUINI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 TRADE CENTRE WAY # 140
PORTAGE MI
49002-0411
US

IV. Provider business mailing address

650 TRADE CENTRE WAY
PORTAGE MI
49002-0411
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-3732
  • Fax:
Mailing address:
  • Phone: 517-882-3732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704377613
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: