MEDICARE: IGUELLE BERNARD PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704282267	MI

General Provider Information

NPI Number	:	1467183517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IGUELLE BERNARD PMHNP-BC

Provider Business Mailing Address
First Line	:	6920 KALAMAZOO AVE SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-8413
Country	:	US
Telephone Number	:	616-929-3617
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 MEDICAL PARK DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3610
Country	:	US
Telephone Number	:	616-929-3617
Fax Number	:

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

Provider Enumeration Date	:	06/20/2022
Last Update Date	:	03/21/2024

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