Provider Demographics
NPI:1467445619
Name:GAULTIER, TONI RENEE (NP)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:RENEE
Last Name:GAULTIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 6TH ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2359
Mailing Address - Country:US
Mailing Address - Phone:231-935-2400
Mailing Address - Fax:231-935-2424
Practice Address - Street 1:1221 6TH ST
Practice Address - Street 2:SUITE 306
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2359
Practice Address - Country:US
Practice Address - Phone:231-935-2400
Practice Address - Fax:231-935-2424
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITG127054363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4397291Medicaid
MI381961572OtherFEDERAL TAX ID NUMBER
MI381961572OtherFEDERAL TAX ID NUMBER