# NORTHRIDGE FAMILY PRACTICE LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1891712493
- **Authorized official:** MRS. DEBRA KAYE PROVOAST RN MSN FNP (MANAGING OFFICER)
- **Authorized official phone:** (989) 728-6000

## Contact information

- **Practice address:** 3190 NORTHRIDGE DRIVE, HALE, MI 48739-9276
- **Practice address phone:** (989) 728-6000
- **Practice address fax:** (989) 728-6003
- **Mailing address:** PO BOX 279, HALE, MI 48739-0279
- **Mailing address phone:** (989) 728-6000
- **Mailing address fax:** (989) 728-6003

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 4301061417 | MI | — |
| 363L00000X | Nurse Practitioner | 4704148660 | MI | — |
| 363L00000X | Nurse Practitioner | 4704173663 | MI | Yes |
| 363LF0000X | Family Nurse Practitioner | 4704245250 | MI | — |
| 363LF0000X | Family Nurse Practitioner | 4704283185 | MI | — |

## Other

- **Enumeration date:** 07/17/2006
- **Last updated:** 11/02/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1017858 | MCLAREN DEB PROVOAST | MI |
| 01 | — | 1017859 | MCLAREN | MI |
| 05 | — | 104289418 | — | MI |
| 05 | — | 105230710 | — | MI |
| 05 | — | 105235126 | — | MI |
| 01 | — | 4704283185 | LINDSEY LICENSE | MI |
| 01 | — | BW148660 | BETH WEAVER LICENSE | MI |
| 01 | — | DD9334 | RAILROAD MEDICARE | MI |
| 01 | — | DP173663 | DEBBIE PROVOAST LICENSE | MI |
| 01 | — | MA061417 | MOHAMED ALI | — |
| 01 | — | OC51020 | BLUE CROSS BLUE SHIELD | — |
| 01 | — | RAILROAD MEDICARE | P00261196 | MI |