Provider Demographics
NPI:1700994860
Name:GONYEA, KIMBERLY ANN (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:GONYEA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:36115 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-793-6140
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:3600 E FULTON
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-1322
Practice Address - Country:US
Practice Address - Phone:616-949-4971
Practice Address - Fax:616-248-3530
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704153798363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKG153798OtherBLUE SHIELD
MIKG153798OtherBLUE SHIELD