Provider Demographics
NPI:1386521623
Name:HERSHA, COURTNEY LEE (FNP-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEE
Last Name:HERSHA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:269-552-2823
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:7901 ANGLING RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0714
Practice Address - Country:US
Practice Address - Phone:269-324-8405
Practice Address - Fax:269-324-8441
Is Sole Proprietor?:No
Enumeration Date:2025-08-19
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1386521623Medicaid