Healthcare Provider Details

I. General information

NPI: 1669059796
Provider Name (Legal Business Name): LEAH MAE MERRICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEAH MAE KIMMINAU PA-C

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2690 S CLEVELAND AVE
SAINT JOSEPH MI
49085-3002
US

IV. Provider business mailing address

2690 S CLEVELAND AVE
SAINT JOSEPH MI
49085-3002
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-2800
  • Fax: 269-428-7177
Mailing address:
  • Phone: 269-428-2800
  • Fax: 269-428-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010350
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: