Healthcare Provider Details

I. General information

NPI: 1306709282
Provider Name (Legal Business Name): HAILEY VAN HAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 FAIRFIELD AVE NW
GRAND RAPIDS MI
49504-3743
US

IV. Provider business mailing address

857 FAIRFIELD AVE NW
GRAND RAPIDS MI
49504-3743
US

V. Phone/Fax

Practice location:
  • Phone: 616-773-9518
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704345684
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: