Healthcare Provider Details

I. General information

NPI: 1407778061
Provider Name (Legal Business Name): TANYA WONNACOTT DNP, RN, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LAFAYETTE AVE SE
GRAND RAPIDS MI
49503-4600
US

IV. Provider business mailing address

10878 MARY ELIZ CT
ALLENDALE MI
49401-8398
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-0801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704356026
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1437192374
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: