Healthcare Provider Details

I. General information

NPI: 1700832995
Provider Name (Legal Business Name): PAMELA VANDUSEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

1900 44TH ST SE
KENTWOOD MI
49508
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-1835
  • Fax: 616-685-1846
Mailing address:
  • Phone: 616-965-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704165365
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: