Provider Demographics
NPI:1154707743
Name:ALFREDSON, KATIE M
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:ALFREDSON
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 1:216 TERRA CIR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2766
Mailing Address - Country:US
Mailing Address - Phone:231-672-3648
Mailing Address - Fax:231-672-3838
Practice Address - Street 1:1212 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1879
Practice Address - Country:US
Practice Address - Phone:231-672-3648
Practice Address - Fax:231-672-3838
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704283005363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology