Provider Demographics
NPI:1972849362
Name:LIPA, JALIE MOWRY (NP-BC, CRNA)
Entity type:Individual
Prefix:
First Name:JALIE
Middle Name:MOWRY
Last Name:LIPA
Suffix:
Gender:F
Credentials:NP-BC, CRNA
Other - Prefix:
Other - First Name:JALIE
Other - Middle Name:J
Other - Last Name:MOWRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-BC, CRNA
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ATKINSON DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1906
Practice Address - Country:US
Practice Address - Phone:231-845-2539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704232682363LA2200X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health