Provider Demographics
NPI:1215473756
Name:MOTTON, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MOTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:MOTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:5100 LITTLE PAW PAW LAKE RD
Mailing Address - Street 2:142
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-9562
Mailing Address - Country:US
Mailing Address - Phone:269-468-3626
Mailing Address - Fax:
Practice Address - Street 1:2627 E BELTLINE AVE SE
Practice Address - Street 2:STE 210
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5975
Practice Address - Country:US
Practice Address - Phone:616-285-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-08
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703089252164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse