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General NPI Number Information
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NPI Number | 1497178644
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Entity Type | Individual
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Provider Name | LISA STAPLE RN
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Gender | Female
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Dates
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Enumeration Date | 01/23/2014
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Last Update Date | 01/23/2014
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Provider Practice Location Address
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Address Line | 3333 36TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49512-2809
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Country | US
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Telephone | 616-954-3540
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Fax |
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Provider Business Mailing Address
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Address Line | 74 E 34TH ST
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City | HOLLAND
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State | MI
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Zip | 49423-7004
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Country | US
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Telephone | 616-405-2854
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 4704254719
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License Number State | MI
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