Healthcare Provider Details

I. General information

NPI: 1861345282
Provider Name (Legal Business Name): OCTAVIA SHONTAE MYLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 IONIA AVE SW APT 302
GRAND RAPIDS MI
49503-6411
US

IV. Provider business mailing address

350 IONIA AVE SW APT 302
GRAND RAPIDS MI
49503-6411
US

V. Phone/Fax

Practice location:
  • Phone: 989-443-9699
  • Fax:
Mailing address:
  • Phone: 989-443-9699
  • 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: