Healthcare Provider Details

I. General information

NPI: 1730673468
Provider Name (Legal Business Name): ANNA DERR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 36TH ST SE
GRAND RAPIDS MI
49512-2809
US

IV. Provider business mailing address

3333 36TH ST SE
GRAND RAPIDS MI
49512-2809
US

V. Phone/Fax

Practice location:
  • Phone: 616-726-5165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number28243182A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: