Healthcare Provider Details

I. General information

NPI: 1174183057
Provider Name (Legal Business Name): KATHERINE MURILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 LAFAYETTE AVE NE
GRAND RAPIDS MI
49505-5092
US

IV. Provider business mailing address

1211 LAFAYETTE AVE NE
GRAND RAPIDS MI
49505-5092
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-8800
  • Fax:
Mailing address:
  • Phone: 616-336-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009210
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: