Healthcare Provider Details

I. General information

NPI: 1083623128
Provider Name (Legal Business Name): KATHLEEN BULLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GRANDVILLE AVE SW
GRAND RAPIDS MI
49503-4920
US

IV. Provider business mailing address

245 STATE ST SE
GRAND RAPIDS MI
49503-4328
US

V. Phone/Fax

Practice location:
  • Phone: 616-913-8400
  • Fax: 616-742-1322
Mailing address:
  • Phone: 616-913-1808
  • Fax: 616-913-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704096205
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: