Basic Information
| Provider Information | |||||||||
| NPI: | 1992785505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTMAN | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417806 | ||||||||
| FaxNumber: | 2693418743 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | STE M351, BRONSON WOMENS SERVICES | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417979 | ||||||||
| FaxNumber: | 2693416261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 4704112162 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 3073870 | 05 | MI | MEDICAID |