Provider Demographics
NPI:1598021487
Name:REVITTE, KAREN M (NP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:REVITTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:M
Other - Last Name:CABANSAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 BRETON RD SE
Practice Address - Street 2:SUITE 102
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5262
Practice Address - Country:US
Practice Address - Phone:616-391-9700
Practice Address - Fax:616-391-9707
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704207782363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner