Provider Demographics
NPI:1730645276
Name:MERLIN, CAMILLE HAYNES (NP)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:HAYNES
Last Name:MERLIN
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 1:1906 DEXTER AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4078
Mailing Address - Country:US
Mailing Address - Phone:734-395-7504
Mailing Address - Fax:
Practice Address - Street 1:2907 PLEASANT VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4305
Practice Address - Country:US
Practice Address - Phone:814-943-8164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704275829363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017028390OtherANCC
MI4704275829OtherDEPARTMENT OF LICENSING