Healthcare Provider Details

I. General information

NPI: 1316618085
Provider Name (Legal Business Name): SARAH CATHERINE ELLIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH CATHERINE PERSONKE FNP

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-8614
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-267-8860
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704330329
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: