Healthcare Provider Details

I. General information

NPI: 1235413758
Provider Name (Legal Business Name): KELLY SUZANNE PETERSON ND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 FULTON ST W SUITE B
GRAND RAPIDS MI
49504
US

IV. Provider business mailing address

638 FULTON ST W SUITE B
GRAND RAPIDS MI
49504
US

V. Phone/Fax

Practice location:
  • Phone: 616-264-6556
  • Fax: 616-432-3564
Mailing address:
  • Phone: 616-264-6556
  • Fax: 616-432-3564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number11-1263
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number009.0134076
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: