Basic Information
| Provider Information | |||||||||
| NPI: | 1982623633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLOTIRA | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169131808 | ||||||||
| FaxNumber: | 6169131818 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LAFAYETTE AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167323098 | ||||||||
| FaxNumber: | 6167323095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 4704081078 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 4878598 | 05 | MI | MEDICAID | 4577450 | 05 | MI | MEDICAID |