Provider Demographics
NPI:1356734297
Name:LOOMIS, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:LOOMIS
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 1:7422 S ARDMORE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8049
Mailing Address - Country:US
Mailing Address - Phone:517-395-5938
Mailing Address - Fax:
Practice Address - Street 1:141 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1201
Practice Address - Country:US
Practice Address - Phone:517-395-5938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47030835693747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant