Healthcare Provider Details

I. General information

NPI: 1023714177
Provider Name (Legal Business Name): TIMOTHY RUSSELL LEONARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

2373 64TH ST SW STE 2500
BYRON CENTER MI
49315-7978
US

V. Phone/Fax

Practice location:
  • Phone: 616-465-5910
  • Fax: 616-465-5911
Mailing address:
  • Phone: 616-465-5910
  • Fax: 616-465-5911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704363385
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: