Provider Demographics
NPI:1255735494
Name:DEGRAVE, MARY JEAN (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:DEGRAVE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E21892 CROOKED LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969-9740
Mailing Address - Country:US
Mailing Address - Phone:906-285-2605
Mailing Address - Fax:
Practice Address - Street 1:1721 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3637
Practice Address - Country:US
Practice Address - Phone:906-774-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704236417363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily