Healthcare Provider Details

I. General information

NPI: 1679904379
Provider Name (Legal Business Name): TARA BROOKE SCHULTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2531
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-267-7900
  • Fax: 616-267-7901
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704320597
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: