Healthcare Provider Details

I. General information

NPI: 1427400019
Provider Name (Legal Business Name): CARIDANIELLE ZUKOFF CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 WEALTHY ST SE
GRAND RAPIDS MI
49506-2921
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-7870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704319706
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: