Provider Demographics
NPI:1689484560
Name:BERTOLONE, NOAH DANIEL (FNP-C)
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:DANIEL
Last Name:BERTOLONE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10894 VINE LEAF CIR
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9883 US 31
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MI
Practice Address - Zip Code:49437-9501
Practice Address - Country:US
Practice Address - Phone:231-893-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-08-21
Deactivation Date:2025-06-11
Deactivation Code:
Reactivation Date:2025-08-11
Provider Licenses
StateLicense IDTaxonomies
MI4704355354363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care