Basic Information
| Provider Information | |||||||||
| NPI: | 1356058572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CELESTINO | ||||||||
| FirstName: | SAVANNAH | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 E CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486242215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894269295 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 655 E CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486242215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894269295 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2022 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 4704334076 | MI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 4704334076 | 01 | MI | NURSING LICENSE | OTHER |