Provider Demographics
NPI:1376073379
Name:HERMANN, CLAYTON REED (BA)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:REED
Last Name:HERMANN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3492 LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4338
Mailing Address - Country:US
Mailing Address - Phone:616-940-0040
Mailing Address - Fax:
Practice Address - Street 1:3492 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4338
Practice Address - Country:US
Practice Address - Phone:616-940-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider