Healthcare Provider Details

I. General information

NPI: 1508315359
Provider Name (Legal Business Name): PRUDENCE WARREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

846 BALLARD ST SE
GRAND RAPIDS MI
49507-2037
US

IV. Provider business mailing address

4829 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-9747
US

V. Phone/Fax

Practice location:
  • Phone: 616-821-0584
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: