Provider Demographics
NPI:1326764317
Name:KWAK, INGRID (FNP)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:KWAK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 HOLLYWOOD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9151
Mailing Address - Country:US
Mailing Address - Phone:269-985-1000
Mailing Address - Fax:269-983-3181
Practice Address - Street 1:3950 HOLLYWOOD RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9151
Practice Address - Country:US
Practice Address - Phone:269-985-1000
Practice Address - Fax:269-983-3181
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704315366163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse