Provider Demographics
NPI:1487045753
Name:PRUDHOMME, RACHEL ANNE (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:ANNE
Last Name:PRUDHOMME
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22234 220TH AVE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:MI
Mailing Address - Zip Code:49338-9455
Mailing Address - Country:US
Mailing Address - Phone:231-742-0117
Mailing Address - Fax:
Practice Address - Street 1:2730 5 MILE RD NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6518
Practice Address - Country:US
Practice Address - Phone:616-426-9401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309686163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse