Healthcare Provider Details

I. General information

NPI: 1730628199
Provider Name (Legal Business Name): KARLY ROSE MCLEOD HISER D.N.P., RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KARLY ROSE MCLEOD

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE STE 300
GRAND RAPIDS MI
49503-2527
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704324281
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: