Provider Demographics
NPI:1649645193
Name:HOWARD, MERCELLE SUZANNE
Entity type:Individual
Prefix:
First Name:MERCELLE
Middle Name:SUZANNE
Last Name:HOWARD
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-8242
Mailing Address - Fax:616-391-8317
Practice Address - Street 1:80 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6980
Practice Address - Country:US
Practice Address - Phone:616-391-2842
Practice Address - Fax:616-391-8317
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460Medicare PIN