Provider Demographics
NPI:1750108734
Name:MANSARAY, KURTRICE SHARLYNN (CHW)
Entity type:Individual
Prefix:
First Name:KURTRICE
Middle Name:SHARLYNN
Last Name:MANSARAY
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1918
Mailing Address - Country:US
Mailing Address - Phone:616-306-0794
Mailing Address - Fax:
Practice Address - Street 1:700 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-306-0794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1298172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker