Healthcare Provider Details

I. General information

NPI: 1194092957
Provider Name (Legal Business Name): LAURA M DEFRAIA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4069 LAKE DR SE STE 118
GRAND RAPIDS MI
49546-8816
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-267-8520
  • Fax: 616-267-7927
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704307776
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: