NPIMap

Organization Active NPI

Northridge Family Practice LLC

  • Nurse Practitioner
  • Hale, MI
National Provider Identifier
1891712493
Registry record updated Nov 2, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
License
4704173663 Issued in MI
Legal business name
NORTHRIDGE FAMILY PRACTICE LLC
Practice address
3190 Northridge Drive
Hale, MI 48739-9276
Phone
(989) 728-6000
Fax
(989) 728-6003
NPI assigned
Jul 17, 2006
Last updated
Nov 2, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 2, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Debra Kaye Provoast, RN MSN FNPNPI 1033107271
Title
Managing Officer
Phone
(989) 728-6000

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 4301061417 MI
Nurse Practitioner 363L00000X 4704173663 MI Primary
Nurse Practitioner 363L00000X 4704148660 MI
Family Nurse Practitioner 363LF0000X 4704245250 MI
Family Nurse Practitioner 363LF0000X 4704283185 MI

Addresses

Primary practice location

3190 Northridge Drive
Hale, MI 48739-9276

Mailing address

PO Box 279
Hale, MI 48739-0279
Phone (989) 728-6000

Other identifiers 12

IdentifierTypeStateIssuer
1017859OtherMIMCLAREN
104289418MedicaidMI
105235126MedicaidMI
105230710MedicaidMI
BW148660OtherMIBETH WEAVER LICENSE
1017858OtherMIMCLAREN DEB PROVOAST
4704283185OtherMILINDSEY LICENSE
DP173663OtherMIDEBBIE PROVOAST LICENSE
DD9334OtherMIRAILROAD MEDICARE
MA061417OtherMOHAMED ALI
OC51020OtherBLUE CROSS BLUE SHIELD
RAILROAD MEDICAREOtherMIP00261196

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153094400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1446422400000",
    "number": "1891712493",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 279",
            "city": "HALE",
            "state": "MI",
            "postal_code": "487390279",
            "telephone_number": "989-728-6000",
            "fax_number": "989-728-6003"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3190 NORTHRIDGE DRIVE",
            "city": "HALE",
            "state": "MI",
            "postal_code": "487399276",
            "telephone_number": "989-728-6000",
            "fax_number": "989-728-6003"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHRIDGE FAMILY PRACTICE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-17",
        "last_updated": "2015-11-02",
        "status": "A",
        "authorized_official_last_name": "PROVOAST",
        "authorized_official_first_name": "DEBRA",
        "authorized_official_middle_name": "KAYE",
        "authorized_official_title_or_position": "MANAGING OFFICER",
        "authorized_official_telephone_number": "989-728-6000",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "RN  MSN  FNP"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MI",
            "license": "4301061417",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "MI",
            "license": "4704173663",
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "MI",
            "license": "4704148660",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MI",
            "license": "4704245250",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MI",
            "license": "4704283185",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MCLAREN",
            "identifier": "1017859",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "104289418",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "105235126",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "105230710",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BETH WEAVER LICENSE",
            "identifier": "BW148660",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MCLAREN DEB PROVOAST",
            "identifier": "1017858",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LINDSEY LICENSE",
            "identifier": "4704283185",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEBBIE PROVOAST LICENSE",
            "identifier": "DP173663",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "DD9334",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MOHAMED ALI",
            "identifier": "MA061417",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "OC51020",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "P00261196",
            "identifier": "RAILROAD MEDICARE",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hale, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.