Healthcare Provider Details

I. General information

NPI: 1588424964
Provider Name (Legal Business Name): KAITLYN ROSE HUFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

420 BAYBERRY POINTE DR NW APT H
GRAND RAPIDS MI
49534-4647
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax:
Mailing address:
  • Phone: 269-569-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: