=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891712493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHRIDGE FAMILY PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 11/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3190 NORTHRIDGE DRIVE
-----------------------------------------------------
City | HALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48739-9276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-728-6000
-----------------------------------------------------
Fax | 989-728-6003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 279
-----------------------------------------------------
City | HALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48739-0279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-728-6000
-----------------------------------------------------
Fax | 989-728-6003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING OFFICER
-----------------------------------------------------
Name | MRS. DEBRA KAYE PROVOAST
-----------------------------------------------------
Credential | RN MSN FNP
-----------------------------------------------------
Telephone | 989-728-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301061417
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704148660
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704245250
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704283185
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704173663
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------