Provider Demographics
NPI:1902340631
Name:MESSERSMITH, SALLY JO
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:JO
Last Name:MESSERSMITH
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 1:7247 TRAVERSE AVE
Mailing Address - Street 2:P.O. BOX 167
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-9806
Mailing Address - Country:US
Mailing Address - Phone:231-882-0100
Mailing Address - Fax:
Practice Address - Street 1:7247 TRAVERSE AVE
Practice Address - Street 2:
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616-9806
Practice Address - Country:US
Practice Address - Phone:231-882-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X/TECHNICIA2471C1106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C1106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiac-Interventional Technology