Provider Demographics
NPI:1093422172
Name:VIDRI, EMILY ROSE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:VIDRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7943 KIRKWOOD TRL SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-8974
Mailing Address - Country:US
Mailing Address - Phone:616-307-1911
Mailing Address - Fax:
Practice Address - Street 1:1000 EAST PARIS AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8383
Practice Address - Country:US
Practice Address - Phone:616-685-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704319248363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care