Healthcare Provider Details

I. General information

NPI: 1508615436
Provider Name (Legal Business Name): KATE MAURA DOUGLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 WEALTHY ST SE FL 5
GRAND RAPIDS MI
49506-2921
US

IV. Provider business mailing address

205 DIVISION AVE S UNIT 104205
GRAND RAPIDS MI
49503-4508
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-3800
  • Fax:
Mailing address:
  • Phone: 269-967-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: