Provider Demographics
NPI:1699023259
Name:BOGGIANO, THERESE L (RN)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:L
Last Name:BOGGIANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:
Other - Last Name:KUBIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:131 W SEAWAY DR
Mailing Address - Street 2:STE 200
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3761
Mailing Address - Country:US
Mailing Address - Phone:616-494-5698
Mailing Address - Fax:
Practice Address - Street 1:12265 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8613
Practice Address - Country:US
Practice Address - Phone:616-494-5698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278126163WP0807X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent