Basic Information
| Provider Information | |||||||||
| NPI: | 1104911171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSEPH | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 E TUTTLE RD | ||||||||
| Address2: | LOT 162 | ||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488468614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271272 | ||||||||
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| Practice Location | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
| FaxNumber: | 6165270538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704177141 | MI | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1715928 | 05 | MI | MEDICAID |