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General NPI Number Information
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NPI Number | 1669280384
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Entity Type | Individual
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Provider Name | MIKALA RAE GUALTIERI PA
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Gender | Female
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Dates
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Enumeration Date | 12/27/2024
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 3570 HENRY ST STE 120
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City | NORTON SHORES
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State | MI
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Zip | 49441-4576
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Country | US
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Telephone | 231-672-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 892 COLLEGE AVE
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City | HOLLAND
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State | MI
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Zip | 49423-7050
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Country | US
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Telephone | 616-510-6407
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5601012938APP24
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601012938
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License Number State | MI
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