Healthcare Provider Details

I. General information

NPI: 1568429496
Provider Name (Legal Business Name): PATRICIA A LEWIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA A TIBALDO FNP

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 S FRONT ST
GRANT MI
49327-9701
US

IV. Provider business mailing address

2627 E BELTLINE AVE SE STE 220
GRAND RAPIDS MI
49546-5937
US

V. Phone/Fax

Practice location:
  • Phone: 844-537-1036
  • Fax: 833-626-1945
Mailing address:
  • Phone: 844-537-1036
  • Fax: 833-626-1945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704192304
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: