Healthcare Provider Details

I. General information

NPI: 1093422172
Provider Name (Legal Business Name): EMILY ROSE VIDRI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 LEONARD ST NE STE 3
GRAND RAPIDS MI
49525-6902
US

IV. Provider business mailing address

7943 KIRKWOOD TRL SE
ALTO MI
49302-8974
US

V. Phone/Fax

Practice location:
  • Phone: 616-317-7246
  • Fax: 616-920-6540
Mailing address:
  • Phone: 616-307-1911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704319248
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: