Healthcare Provider Details

I. General information

NPI: 1295652410
Provider Name (Legal Business Name): CODY ROBERT SMITH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 MICHIGAN AVE
HOLLAND MI
49423-4918
US

IV. Provider business mailing address

3554 CHIPPEWA DR
NORTON SHORES MI
49441-4243
US

V. Phone/Fax

Practice location:
  • Phone: 616-494-4175
  • Fax:
Mailing address:
  • Phone: 231-923-6435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number4704324532
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: