Provider Demographics
NPI:1346331139
Name:DEGRAM, DEBRA SUE (CNM)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:DEGRAM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4944
Mailing Address - Country:US
Mailing Address - Phone:616-392-5973
Mailing Address - Fax:616-392-1646
Practice Address - Street 1:664 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4944
Practice Address - Country:US
Practice Address - Phone:616-392-5973
Practice Address - Fax:616-392-1646
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704132616367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0876976OtherBCBSM IND. PIN
MI420G012010OtherBCBSM GRP PIN
MIDF4619OtherMEDICARE RR GRP PIN
MI0G01201OtherMEDICARE GRP PIN
MIDF4619OtherMEDICARE RR GRP PIN