Provider Demographics
NPI:1346379401
Name:MOHRHARDT, PAM (LPN)
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:
Last Name:MOHRHARDT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16253 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:NUNICA
Mailing Address - State:MI
Mailing Address - Zip Code:49448-9648
Mailing Address - Country:US
Mailing Address - Phone:616-847-0651
Mailing Address - Fax:
Practice Address - Street 1:800 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-5848
Practice Address - Country:US
Practice Address - Phone:616-456-6135
Practice Address - Fax:616-771-9779
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703042784164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse