Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 4704075934 | MI |
NPI | 1013089630 |
---|---|
Provider Name | Ms. Roberta J Walsh |
First Address | Grand Rapids, MI 49503-4513 |
Second Address | Grand Rapids, MI 49503-4513 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4807934 | (05) | MI |