Healthcare Provider Details

I. General information

NPI: 1275508632
Provider Name (Legal Business Name): TRISHA LYNN FARRELL CNM, WHNP, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 12/28/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 S BAILEY AVE STE 200
SOUTH HAVEN MI
49090-6743
US

IV. Provider business mailing address

1020 11TH AVE USS RED ROVER BUILDING 1523
GREAT LAKES IL
60088-3102
US

V. Phone/Fax

Practice location:
  • Phone: 269-639-2720
  • Fax:
Mailing address:
  • Phone: 847-688-5568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704176647
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number4704176647
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: