Healthcare Provider Details

I. General information

NPI: 1255988838
Provider Name (Legal Business Name): KIRI DEYOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

878 GRANDVILLE AVE SW APT 4
GRAND RAPIDS MI
49503-4985
US

IV. Provider business mailing address

878 GRANDVILLE AVE SW APT 4
GRAND RAPIDS MI
49503-4985
US

V. Phone/Fax

Practice location:
  • Phone: 616-706-6334
  • Fax:
Mailing address:
  • Phone: 616-706-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: