Provider Demographics
NPI:1154849677
Name:WHITLEY, ROSHAWN NICHOL
Entity Type:Individual
Prefix:
First Name:ROSHAWN
Middle Name:NICHOL
Last Name:WHITLEY
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 1:891 MARYLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6005
Mailing Address - Country:US
Mailing Address - Phone:616-608-7778
Mailing Address - Fax:616-635-2036
Practice Address - Street 1:891 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505
Practice Address - Country:US
Practice Address - Phone:616-608-7778
Practice Address - Fax:616-635-2036
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant