Healthcare Provider Details

I. General information

NPI: 1790353043
Provider Name (Legal Business Name): JESSIE ROSLONIEC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4743
US

IV. Provider business mailing address

10837 64TH AVE
ALLENDALE MI
49401-9777
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-2473
  • Fax:
Mailing address:
  • Phone: 616-291-4303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303028105
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: