Healthcare Provider Details

I. General information

NPI: 1114841756
Provider Name (Legal Business Name): JAINYA SANNOH
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 SUMMER CIR SE
GRAND RAPIDS MI
49548-7021
US

IV. Provider business mailing address

364 SUMMER CIR SE
GRAND RAPIDS MI
49548-7021
US

V. Phone/Fax

Practice location:
  • Phone: 616-308-0608
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703111106
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: