Healthcare Provider Details

I. General information

NPI: 1467949362
Provider Name (Legal Business Name): KERIANNE FULLIN MD/MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 07/14/2024
Certification Date: 07/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRADFORD ST NE
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

2900 BRADFORD ST NE
GRAND RAPIDS MI
49525-6427
US

V. Phone/Fax

Practice location:
  • Phone: 616-885-5000
  • Fax: 616-885-5020
Mailing address:
  • Phone: 616-885-5000
  • Fax: 616-885-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number4301511930
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: