Healthcare Provider Details

I. General information

NPI: 1487586772
Provider Name (Legal Business Name): LATESHA LEWIS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2153 FRANCIS AVE SE
GRAND RAPIDS MI
49507-3016
US

IV. Provider business mailing address

2153 FRANCIS AVE SE
GRAND RAPIDS MI
49507-3016
US

V. Phone/Fax

Practice location:
  • Phone: 616-405-0541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703122727
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: