Healthcare Provider Details

I. General information

NPI: 1982623633
Provider Name (Legal Business Name): NANCY A WOLOTIRA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE
GRAND RAPIDS MI
49503-4600
US

IV. Provider business mailing address

245 STATE ST SE
GRAND RAPIDS MI
49503-4328
US

V. Phone/Fax

Practice location:
  • Phone: 616-732-3098
  • Fax: 616-732-3095
Mailing address:
  • Phone: 616-913-1808
  • Fax: 616-913-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704081078
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: