Individual
DEBRA K PROVOAST
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
3190 NORTHRIDGE DRIVE, HALE, MI 48739-9276
(989) 728-6000
(989) 728-6003
Mailing address
PO BOX 279, HALE, MI 48739-0279
(989) 728-6000
(989) 728-6003
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
4704173663
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
105235126
—
MI
01
—
500C510200
BCBS
MI
01
—
DP173663
LICENSE
MI
Enumeration date
10/12/2005
Last updated
03/24/2014
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