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Get MI LARA/ED-205 2013-2024

/13) www.michigan.gov/healthlicense MICHIGAN HEALTH PROFESSIONALS – REPORT OF CHANGE IN STAFF PRIVILEGES Section 333.20175 of the Michigan Public Health Code, 1978 PA 368, as amended, provides the criteria for reporting staff changes. Licensee’s First Name: Middle Name: Last Name: Street Address: City: State: Michigan Professional License Number: Period of Time on Facility Staff: FROM: Did the licensee resign? Yes No Zip Code: Type of Licensure (MD, RN, etc.): Telephone Number wi.

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