Healthcare Provider Details

I. General information

NPI: 1083191019
Provider Name (Legal Business Name): KATHERINE MARIE WARNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE ROE NP

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 52ND ST SE
GRAND RAPIDS MI
49512-9637
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-656-3700
  • Fax: 616-656-3701
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704280721
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: