Healthcare Provider Details

I. General information

NPI: 1710918883
Provider Name (Legal Business Name): RENEE K HIBMA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5498 109TH AVE
PULLMAN MI
49450
US

IV. Provider business mailing address

50 INDUSTRIAL PARK DR
BANGOR MI
49013
US

V. Phone/Fax

Practice location:
  • Phone: 269-236-5021
  • Fax: 269-236-5411
Mailing address:
  • Phone: 269-427-7937
  • Fax: 269-427-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704183457
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: