Provider Demographics
NPI:1366117533
Name:DEFAY, JUANITA G (RN, BAS)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:G
Last Name:DEFAY
Suffix:
Gender:F
Credentials:RN, BAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S BENTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-9782
Mailing Address - Country:US
Mailing Address - Phone:269-759-4823
Mailing Address - Fax:
Practice Address - Street 1:4000 PORTAGE ST STE 113
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-4962
Practice Address - Country:US
Practice Address - Phone:269-759-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704191219163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse