Healthcare Provider Details

I. General information

NPI: 1790783926
Provider Name (Legal Business Name): TANIA DEE VANDYKE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 WISCONSIN ST STE 301
GRAND HAVEN MI
49417-2472
US

IV. Provider business mailing address

1310 WISCONSIN ST STE 101
GRAND HAVEN MI
49417-2472
US

V. Phone/Fax

Practice location:
  • Phone: 616-296-1550
  • Fax: 616-296-1554
Mailing address:
  • Phone: 616-296-1550
  • Fax: 616-296-6155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704145235
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704145235
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: