Healthcare Provider Details

I. General information

NPI: 1902316490
Provider Name (Legal Business Name): ALEX DALE BYLSMA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1787 GRAND RIDGE CT NE STE 101
GRAND RAPIDS MI
49525-7042
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW MEDICAL ADMINISTRATION
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-4540
  • Fax: 616-252-4595
Mailing address:
  • Phone: 616-252-3243
  • Fax: 616-252-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704306035
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: