MEDICARE: SUSAN KAY VERMERRIS

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	164W00000X	Licensed Practical Nurse	4703041268	MI

General Provider Information

NPI Number	:	1407446503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KAY VERMERRIS

Provider Business Mailing Address
First Line	:	2362 MIDVALE ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5700
Country	:	US
Telephone Number	:	616-826-0525
Fax Number	:

Provider Business Practice Location Address
First Line	:	2362 MIDVALE ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5700
Country	:	US
Telephone Number	:	616-826-0525
Fax Number	:

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

Provider Enumeration Date	:	01/22/2021
Last Update Date	:	01/22/2021

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