Provider Demographics
NPI:1689484560
Name:BERTOLONE, NOAH DANIEL
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:DANIEL
Last Name:BERTOLONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10894 VINE LEAF CIR
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-672-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704355354163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency