Healthcare Provider Details

I. General information

NPI: 1568292241
Provider Name (Legal Business Name): AMY MARIE DERUS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY MARIE EVITTS RN

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 867
WHITE CLOUD MI
49349-0867
US

IV. Provider business mailing address

4767 E MONROE RD
WHITE CLOUD MI
49349-8678
US

V. Phone/Fax

Practice location:
  • Phone: 231-689-7330
  • Fax:
Mailing address:
  • Phone: 231-245-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704284938
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: