Healthcare Provider Details

I. General information

NPI: 1437834652
Provider Name (Legal Business Name): AMANDA NAA ATSWEI LARYEA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

35618 RUTHERFORD ST
CLINTON TOWNSHIP MI
48035-2676
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-6243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5315256772
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: