Healthcare Provider Details

I. General information

NPI: 1912427121
Provider Name (Legal Business Name): KALYSIA ZIMMERMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date: 12/23/2021
Reactivation Date: 02/07/2022

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

1444 WATER ST
EATON RAPIDS MI
48827-1860
US

V. Phone/Fax

Practice location:
  • Phone: 517-489-9211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010954
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: