MEDICARE: KATHRYN MARIE KUMOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704279790	MI

General Provider Information

NPI Number	:	1164396925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN MARIE KUMOR

Provider Business Mailing Address
First Line	:	1345 MONROE AVE NW STE 323
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-4674
Country	:	US
Telephone Number	:	616-512-3210
Fax Number	:	855-231-2592

Provider Business Practice Location Address
First Line	:	1345 MONROE AVE NW STE 323
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-4674
Country	:	US
Telephone Number	:	616-512-3210
Fax Number	:	855-231-2592

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2025
Last Update Date	:	03/24/2026

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