Healthcare Provider Details

I. General information

NPI: 1598168262
Provider Name (Legal Business Name): DANIELLE GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

3940 CAMELOT DR SE
GRAND RAPIDS MI
49546-6006
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-8789
  • Fax: 616-776-1305
Mailing address:
  • Phone: 616-490-1499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6803086666
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: