Provider Demographics
NPI:1255357794
Name:STARR, THERESA K (CNM)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:K
Last Name:STARR
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2373 64TH ST SW
Practice Address - Street 2:STE 1300
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-7974
Practice Address - Country:US
Practice Address - Phone:616-685-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704182692367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100059750AMedicaid
AR132360799Medicaid
AR5X927OtherAR BCBS
Q18018Medicare UPIN
AR132360799Medicaid
5X927Medicare PIN