MEDICARE: DOLORES ANNE HUIZINGA RN

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	163W00000X	Registered Nurse	4704134859	MI

General Provider Information

NPI Number	:	1235407347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOLORES ANNE HUIZINGA RN

Provider Business Mailing Address
First Line	:	9415 E 136TH ST
Second Line	:
City	:	SAND LAKE
State	:	MI
Zip	:	49343-8976
Country	:	US
Telephone Number	:	616-636-8160
Fax Number	:

Provider Business Practice Location Address
First Line	:	9415 E 136TH ST
Second Line	:
City	:	SAND LAKE
State	:	MI
Zip	:	49343-8976
Country	:	US
Telephone Number	:	616-636-8160
Fax Number	:

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

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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