Healthcare Provider Details

I. General information

NPI: 1861208951
Provider Name (Legal Business Name): TIJUNAE DIANE OTTERBRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 BURTON ST SE
GRAND RAPIDS MI
49546-6121
US

IV. Provider business mailing address

4218 BURTON ST SE
GRAND RAPIDS MI
49546-6121
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-0040
  • Fax:
Mailing address:
  • Phone: 616-940-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberMI000059116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: