Healthcare Provider Details

I. General information

NPI: 1184777682
Provider Name (Legal Business Name): MARY KOENEN F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4234
US

IV. Provider business mailing address

72 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4234
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-8774
  • Fax: 616-988-8775
Mailing address:
  • Phone: 616-988-8774
  • Fax: 616-988-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberMK4704154566
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: