Healthcare Provider Details

I. General information

NPI: 1457009094
Provider Name (Legal Business Name): ALEXANDRA ANNE NUTTALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 36TH ST SE
GRAND RAPIDS MI
49548-2319
US

IV. Provider business mailing address

775 36TH ST SE
GRAND RAPIDS MI
49548-2319
US

V. Phone/Fax

Practice location:
  • Phone: 616-791-4130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: