Organization
NORTHRIDGE FAMILY PRACTICE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. DEBRA KAYE PROVOAST RN MSN FNP (MANAGING OFFICER)
(989) 728-6000
Entity
Organization
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
207R00000X
Internal Medicine Physician
4301061417
MI
363L00000X
Nurse Practitioner
4704148660
MI
363L00000X
Nurse Practitioner
Primary
4704173663
MI
363LF0000X
Family Nurse Practitioner
4704245250
MI
363LF0000X
Family Nurse Practitioner
4704283185
MI
Other
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
Enumeration date
07/17/2006
Last updated
11/02/2015
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