Individual
AWA DIA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-9200
Mailing address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(614) 455-9200
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
4704409322
MI
Other
Enumeration date
06/16/2023
Last updated
11/03/2023
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