Healthcare Provider Details

I. General information

NPI: 1053669895
Provider Name (Legal Business Name): JENNIFER LYNN MOILANEN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N BRIDGE ST
SARANAC MI
48881-5121
US

IV. Provider business mailing address

107 N BRIDGE ST
SARANAC MI
48881-5121
US

V. Phone/Fax

Practice location:
  • Phone: 616-642-9408
  • Fax: 616-642-6940
Mailing address:
  • Phone: 616-642-9408
  • Fax: 616-642-6940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704249083
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: