Provider Demographics
NPI:1265569511
Name:PROVENCHER, ANN MARCELLE
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARCELLE
Last Name:PROVENCHER
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 1:665 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43740 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1139
Practice Address - Country:US
Practice Address - Phone:586-469-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704155196163W00000X, 163WC0400X, 163WC1500X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered163WC0400XNursing Service ProvidersRegistered NurseCase Management
Not Answered163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health