Provider Demographics
NPI:1205959848
Name:EBERLY, MAUREEN MIKA
Entity type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:MIKA
Last Name:EBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 JAMES ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9675
Mailing Address - Country:US
Mailing Address - Phone:616-393-5589
Mailing Address - Fax:616-393-5659
Practice Address - Street 1:12251 JAMES ST
Practice Address - Street 2:SUITE 400
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9675
Practice Address - Country:US
Practice Address - Phone:616-393-5589
Practice Address - Fax:616-393-5659
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704141588363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health