Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | 4704278655 | MI |
NPI | 1215308978 |
---|---|
Provider Name | Jennifer Anne Gates |
First Address | Grand Rapids, MI 49506-2053 |
Second Address | Lansing, MI 48912 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/10/2015 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1215308978 | (05) | MI |