=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164658373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALDINE FARLEY NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2009
-----------------------------------------------------
Last Update Date | 05/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 S JACKSON ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-935-0055
-----------------------------------------------------
Fax | 877-467-1700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 COOPER ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49202-3398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-379-1600
-----------------------------------------------------
Fax | 866-761-5657
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704141449
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------