Healthcare Provider Details

I. General information

NPI: 1578065140
Provider Name (Legal Business Name): KALLIE RAE KRAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 KALAMAZOO AVE SE
GRAND RAPIDS MI
49508-3605
US

IV. Provider business mailing address

1809 EDGEWOOD AVE SE
GRAND RAPIDS MI
49506-5112
US

V. Phone/Fax

Practice location:
  • Phone: 616-486-7093
  • Fax:
Mailing address:
  • Phone: 616-723-7491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704280159
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: