Provider Demographics
NPI:1922296730
Name:MERVENNE, LISA ANN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:MERVENNE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 SILVERGRASS DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9552
Mailing Address - Country:US
Mailing Address - Phone:616-447-0102
Mailing Address - Fax:
Practice Address - Street 1:2520 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4696
Practice Address - Country:US
Practice Address - Phone:616-735-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000452314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility