Healthcare Provider Details

I. General information

NPI: 1427568021
Provider Name (Legal Business Name): ELIZABETH DEMAAGD PNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

1045 GRISWOLD ST SE
GRAND RAPIDS MI
49507-3810
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-1090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number20173648
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20173648
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: