=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104513654
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUTENDO MAVUNGA NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2023
-----------------------------------------------------
Last Update Date | 11/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CAMPUS DR
-----------------------------------------------------
City | ALLENDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49401-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-331-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 CAMPUS DR
-----------------------------------------------------
City | ALLENDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49401-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-331-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704326990
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------