Provider Demographics
NPI:1831483296
Name:RONAN, MARY THERESA (RN, BSN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
Last Name:RONAN
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2763 W LAKE DR
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MI
Mailing Address - Zip Code:48074-4603
Mailing Address - Country:US
Mailing Address - Phone:810-984-8576
Mailing Address - Fax:
Practice Address - Street 1:2763 W LAKE DR
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:MI
Practice Address - Zip Code:48074-4603
Practice Address - Country:US
Practice Address - Phone:810-984-8576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704208728163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704208728OtherDEPARTMENT OF COMMUNITY HEALTH - REGISTERED NURSE LICENSE