Provider Demographics
NPI:1619196680
Name:AVERY, ANN M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:M
Last Name:AVERY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:CEDAR
Mailing Address - State:MI
Mailing Address - Zip Code:49621-0057
Mailing Address - Country:US
Mailing Address - Phone:231-228-5344
Mailing Address - Fax:
Practice Address - Street 1:3147 LOGAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4772
Practice Address - Country:US
Practice Address - Phone:231-935-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704077842363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics