Provider Demographics
NPI:1427303452
Name:RICHARD, MARY JO (NP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:RICHARD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:245 CHERRY ST SE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4607
Mailing Address - Country:US
Mailing Address - Phone:616-685-3330
Mailing Address - Fax:616-685-3349
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:SUITE 204
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-685-3330
Practice Address - Fax:616-685-3349
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704131250363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner