Provider Demographics
NPI:1992859250
Name:PUTT, MARY ANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:PUTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:1480 W CENTER RD
Practice Address - Street 2:SUITE 5
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-2143
Practice Address - Country:US
Practice Address - Phone:989-894-4625
Practice Address - Fax:989-494-4626
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704098741363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMETRAHEALTHOtherP00213438CN5519
MI5008702430OtherBLUE CROSS BLUE SHIELD
MI4579356Medicaid
MI1011985OtherMCLAREN HEALTH PLAN
MI5008702430OtherBLUE CROSS BLUE SHIELD