Healthcare Provider Details

I. General information

NPI: 1033717400
Provider Name (Legal Business Name): LAURIE VANCE TRADITIONAL MIDWIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 DALE ST NE
GRAND RAPIDS MI
49505-4717
US

IV. Provider business mailing address

244 DALE ST NE
GRAND RAPIDS MI
49505-4717
US

V. Phone/Fax

Practice location:
  • Phone: 616-914-6041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: