=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164446738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMRA LYNN GROOTHUIS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 03/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12460 RILEY ST
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49424-8217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-399-6500
-----------------------------------------------------
Fax | 616-399-1908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5800 FOREMOST DR SE STE 300
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-7062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-954-9800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704217358
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------