1194201921 NPI number — SHERYL FUNSTON NP-BC

Table of content: SHERYL FUNSTON NP-BC (NPI 1194201921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194201921 NPI number — SHERYL FUNSTON NP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNSTON
Provider First Name:
SHERYL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194201921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 W WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49203-1236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-205-4001
Provider Business Mailing Address Fax Number:
517-205-0126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 W WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49203-1236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-205-4001
Provider Business Practice Location Address Fax Number:
517-205-0126
Provider Enumeration Date:
07/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  4704279646 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)