Provider Demographics
NPI:1215923339
Name:SOUTHWORTH, JOANNE (LPN)
Entity type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-1624
Mailing Address - Country:US
Mailing Address - Phone:269-273-5000
Mailing Address - Fax:269-273-8019
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-1624
Practice Address - Country:US
Practice Address - Phone:269-273-5000
Practice Address - Fax:269-273-8019
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703083082164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid
MI1708146Medicaid