Provider Demographics
NPI:1770242273
Name:MYNSBERGE, MARK GEORGE (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GEORGE
Last Name:MYNSBERGE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 SPIREA
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-6822
Mailing Address - Country:US
Mailing Address - Phone:810-938-8367
Mailing Address - Fax:
Practice Address - Street 1:1002 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1718
Practice Address - Country:US
Practice Address - Phone:517-546-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-12
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704202716163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse