Healthcare Provider Details

I. General information

NPI: 1386132090
Provider Name (Legal Business Name): LEELANAU FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N SAINT JOSEPH ST UNIT K1
SUTTONS BAY MI
49682-8422
US

IV. Provider business mailing address

718 N SAINT JOSEPH ST UNIT K1
SUTTONS BAY MI
49682-8422
US

V. Phone/Fax

Practice location:
  • Phone: 231-386-0088
  • Fax:
Mailing address:
  • Phone: 231-386-0068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA M PAQUETTE
Title or Position: PHYSICIAN
Credential: D O
Phone: 231-342-6596