Healthcare Provider Details

I. General information

NPI: 1417479064
Provider Name (Legal Business Name): ANN LORENA NOVOSEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 07/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE STE 300
GRAND RAPIDS MI
49503-2527
US

IV. Provider business mailing address

100 MICHIGAN STREET, NE MAIL CODE 013
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax:
Mailing address:
  • Phone: 616-267-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301112764
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: