Provider Demographics
NPI:1760897375
Name:BEMBEN, EMILY FOWLER (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:FOWLER
Last Name:BEMBEN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 SHELDON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4234
Mailing Address - Country:US
Mailing Address - Phone:650-814-1276
Mailing Address - Fax:
Practice Address - Street 1:72 SHELDON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4234
Practice Address - Country:US
Practice Address - Phone:616-331-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MN2475459163W00000X
MN6704363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No163W00000XNursing Service ProvidersRegistered Nurse