Provider Demographics
NPI:1497353908
Name:PETIPREN, TIMOTHY JOSEPH
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:PETIPREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49454-1205
Mailing Address - Country:US
Mailing Address - Phone:231-510-3604
Mailing Address - Fax:
Practice Address - Street 1:205 S COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:SCOTTVILLE
Practice Address - State:MI
Practice Address - Zip Code:49454-1205
Practice Address - Country:US
Practice Address - Phone:231-510-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244882163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse