Healthcare Provider Details

I. General information

NPI: 1235760778
Provider Name (Legal Business Name): REBECCA KENNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 NELSON AVE SE
GRAND RAPIDS MI
49507-3731
US

IV. Provider business mailing address

2201 NELSON AVE SE
GRAND RAPIDS MI
49507-3731
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-6904
  • Fax:
Mailing address:
  • Phone: 616-243-6904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703099179
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: