Healthcare Provider Details

I. General information

NPI: 1871130237
Provider Name (Legal Business Name): MACKENZIE ELIZABETH ONDERSMA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 06/29/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 LYON ST
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

143 BOSTWICK AVE NE
GRAND RAPIDS MI
49503-3201
US

V. Phone/Fax

Practice location:
  • Phone: 616-234-4260
  • Fax:
Mailing address:
  • Phone: 616-234-4260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberTCA891
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002802
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: