Provider Demographics
NPI: | 1922445022 |
---|---|
Name: | DULANEY, JENNIFER KAY (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JENNIFER |
Middle Name: | KAY |
Last Name: | DULANEY |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | JENNIFER |
Other - Middle Name: | KAY |
Other - Last Name: | WATERS |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 1848 |
Mailing Address - Street 2: | |
Mailing Address - City: | MUSKEGON |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49443-1848 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 231-672-2120 |
Mailing Address - Fax: | 343-432-7758 |
Practice Address - Street 1: | 3570 HENRY ST STE 120 |
Practice Address - Street 2: | |
Practice Address - City: | NORTON SHORES |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49441-4576 |
Practice Address - Country: | US |
Practice Address - Phone: | 231-672-7000 |
Practice Address - Fax: | 231-728-5041 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2013-05-29 |
Last Update Date: | 2021-03-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
MI | 5101022190 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 0N28430 | Other | GROUP MEDICARE PTAN |