Healthcare Provider Details

I. General information

NPI: 1003672528
Provider Name (Legal Business Name): ANNE THERESE BEAUCHAMP PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 02/22/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 MEDICAL PARK DR SE
GRAND RAPIDS MI
49546-8323
US

IV. Provider business mailing address

1152 48TH ST SE
KENTWOOD MI
49508-4724
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-9610
  • Fax:
Mailing address:
  • Phone: 616-460-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704293806
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: