=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093422172
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY ROSE VIDRI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2022
-----------------------------------------------------
Last Update Date | 04/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2680 LEONARD ST NE STE 3
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-6902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-317-7246
-----------------------------------------------------
Fax | 616-920-6540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7943 KIRKWOOD TRL SE
-----------------------------------------------------
City | ALTO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49302-8974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-307-1911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 4704319248
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------