Healthcare Provider Details

I. General information

NPI: 1952334427
Provider Name (Legal Business Name): ROBERT FRANCIS LIDESTRI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3019 COIT AVE NE
GRAND RAPIDS MI
49505-3376
US

IV. Provider business mailing address

351 ARTHUR ST
MARNE MI
49435-8730
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-9575
  • Fax: 616-365-9480
Mailing address:
  • Phone: 616-677-3200
  • Fax: 616-677-3200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704158200
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: