Healthcare Provider Details

I. General information

NPI: 1245882703
Provider Name (Legal Business Name): REBECCA VENEKLASE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY AVE NW STE 105
GRAND RAPIDS MI
49504-4496
US

IV. Provider business mailing address

801 BROADWAY AVE NW STE 105
GRAND RAPIDS MI
49504-4496
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-7500
  • Fax: 616-685-7511
Mailing address:
  • Phone: 616-685-7500
  • Fax: 616-685-7511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704313199
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: