Healthcare Provider Details

I. General information

NPI: 1659536688
Provider Name (Legal Business Name): LATISHA LYNNE DEYOUNG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 LAFAYETTE AVE SE STE 400
GRAND RAPIDS MI
49503-4677
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-486-6870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704202168
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: