Provider Demographics
NPI:1578841094
Name:FOX, ANNAH NYBLAD (OD)
Entity Type:Individual
Prefix:DR
First Name:ANNAH
Middle Name:NYBLAD
Last Name:FOX
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4526
Mailing Address - Country:US
Mailing Address - Phone:616-965-8200
Mailing Address - Fax:616-940-5366
Practice Address - Street 1:100 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4526
Practice Address - Country:US
Practice Address - Phone:616-965-8200
Practice Address - Fax:616-940-5366
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004794152W00000X
MEOPT929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578841094OtherNPI
1578841094OtherNPI