Healthcare Provider Details

I. General information

NPI: 1508367392
Provider Name (Legal Business Name): ANDREA NICOLE DENNIS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

IV. Provider business mailing address

3470 MASON VIEW DR NE
GRAND RAPIDS MI
49525-9435
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8172
  • Fax:
Mailing address:
  • Phone: 616-745-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501014802
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: