MEDICARE: MRS. ALLISON BOONIE NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	47042288626	MI

General Provider Information

NPI Number	:	1174948384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALLISON BOONIE NP-C

Provider Business Mailing Address
First Line	:	1959 E PARIS AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6272
Country	:	US
Telephone Number	:	616-363-7690
Fax Number	:	616-363-7680

Provider Business Practice Location Address
First Line	:	1959 E PARIS AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6272
Country	:	US
Telephone Number	:	616-363-7690
Fax Number	:	616-363-7680

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2014
Last Update Date	:	02/25/2014

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