Healthcare Provider Details

I. General information

NPI: 1467905133
Provider Name (Legal Business Name): TIFFANY D REBANDT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY D KUIPERS ANP

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 LAFAYETTE AVE SE SUITE 400
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

310 LAFAYETTE AVE SE SUITE 400
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-752-6832
  • Fax: 616-732-8902
Mailing address:
  • Phone: 616-752-6832
  • Fax: 616-732-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704293043
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: