MEDICARE: KALLIE RAE KRAKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	4704280159	MI

General Provider Information

NPI Number	:	1578065140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALLIE RAE KRAKER

Provider Business Mailing Address
First Line	:	1809 EDGEWOOD AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-5112
Country	:	US
Telephone Number	:	616-723-7491
Fax Number	:

Provider Business Practice Location Address
First Line	:	4118 KALAMAZOO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-3605
Country	:	US
Telephone Number	:	616-486-7093
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2018
Last Update Date	:	02/28/2018

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Directions to “ KALLIE RAE KRAKER ” Practice Location

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