Basic Information
| Provider Information | |||||||||
| NPI: | 1740933886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | ANNELISE | ||||||||
| MiddleName: | CLAERR | ||||||||
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| Credential: | AGPCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST. NE, MC 845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 145 MICHIGAN ST NE STE 6300 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2022 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 4704273262 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 4704273262 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.