Provider Demographics
NPI:1134690761
Name:GEBBEN, KOREN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KOREN
Middle Name:
Last Name:GEBBEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 EAST PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6272
Mailing Address - Country:US
Mailing Address - Phone:616-808-2695
Mailing Address - Fax:616-808-2697
Practice Address - Street 1:1959 EAST PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6272
Practice Address - Country:US
Practice Address - Phone:616-808-2695
Practice Address - Fax:616-808-2697
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277013363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704277013OtherLICENSE NUMBER