Basic Information
| Provider Information | |||||||||
| NPI: | 1215473756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOTTON | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | MOTTON | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
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| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5100 LITTLE PAW PAW LAKE RD | ||||||||
| Address2: | 142 | ||||||||
| City: | COLOMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490389562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694683626 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2627 E BELTLINE AVE SE | ||||||||
| Address2: | STE 210 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162855100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2017 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 4703089252 | MI | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.