Healthcare Provider Details

I. General information

NPI: 1942996129
Provider Name (Legal Business Name): KYLEIGH FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

4829 E BELTLINE AVE NE STE 310
GRAND RAPIDS MI
49525-9350
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-5000
  • Fax: 616-281-6459
Mailing address:
  • Phone: 616-279-6414
  • Fax: 616-591-3393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: