=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033654702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE SUSAN WALIGORSKI FNP-BC, PMHNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2017
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1375 N MAIN ST
-----------------------------------------------------
City | LAPEER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48446-1350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-667-5701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5380 HUNTERS CREEK RD
-----------------------------------------------------
City | IMLAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48444-9711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-338-3508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704232878
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 4704232878
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------