Healthcare Provider Details

I. General information

NPI: 1083522791
Provider Name (Legal Business Name): MCKENNA BLAIR NUNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2787 WILSON AVE NW
GRAND RAPIDS MI
49534-7510
US

IV. Provider business mailing address

2624 CORLOT ST
KALAMAZOO MI
49004-1727
US

V. Phone/Fax

Practice location:
  • Phone: 616-915-2066
  • Fax:
Mailing address:
  • Phone: 269-808-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: