Healthcare Provider Details

I. General information

NPI: 1346983459
Provider Name (Legal Business Name): AMANDA KIMBERLY FENN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. AMANDA KIMBERLY BURBANK

II. Dates (important events)

Enumeration Date: 04/16/2022
Last Update Date: 04/16/2022
Certification Date: 04/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 LEONARD ST NE
GRAND RAPIDS MI
49505-5572
US

IV. Provider business mailing address

8576 JASONVILLE CT SE
CALEDONIA MI
49316-8287
US

V. Phone/Fax

Practice location:
  • Phone: 616-460-7647
  • Fax: 616-458-5430
Mailing address:
  • Phone: 847-858-9889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: