Basic Information
| Provider Information | |||||||||
| NPI: | 1720672090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | LINDA | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9045 US HIGHWAY 31 | ||||||||
| Address2: | |||||||||
| City: | BERRIEN SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694732222 | ||||||||
| FaxNumber: | 2694736880 | ||||||||
| Practice Location | |||||||||
| Address1: | 9045 US HIGHWAY 31 | ||||||||
| Address2: | |||||||||
| City: | BERRIEN SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694732222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2021 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704275934 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.