=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265982235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANCY ABRAHAM NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2016
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6465 MILLENNIUM STE 100
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48917-7831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-975-3720
-----------------------------------------------------
Fax | 517-323-7633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6894 MULBERRY LN
-----------------------------------------------------
City | GRAND LEDGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48837-8737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-255-4761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 4704262368
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------