Basic Information
| Provider Information | |||||||||
| NPI: | 1992859250 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUTT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 1480 W CENTER RD | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | ESSEXVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487322143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898944625 | ||||||||
| FaxNumber: | 9894944626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704098741 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | METRAHEALTH | 01 | MI | P00213438CN5519 | OTHER | 5008702430 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 4579356 | 05 | MI | MEDICAID | 1011985 | 01 | MI | MCLAREN HEALTH PLAN | OTHER |