Healthcare Provider Details

I. General information

NPI: 1629615646
Provider Name (Legal Business Name): WOMENS HEALTH COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 KENMOOR AVE SE STE 103
GRAND RAPIDS MI
49546-8626
US

IV. Provider business mailing address

630 KENMOOR AVE SE
GRAND RAPIDS MI
49546-8626
US

V. Phone/Fax

Practice location:
  • Phone: 616-581-0772
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: NISHA MCKENZIE
Title or Position: FOUNDER AND OWNER
Credential: PA-C
Phone: 616-600-4950