Provider Demographics
NPI:1679057517
Name:MENTINK, MICHELE MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:MARIE
Last Name:MENTINK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14174 ELM ROW RD
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-9611
Mailing Address - Country:US
Mailing Address - Phone:517-206-0067
Mailing Address - Fax:
Practice Address - Street 1:400 HINCKLEY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-6152
Practice Address - Country:US
Practice Address - Phone:517-205-8991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274359363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily