Healthcare Provider Details

I. General information

NPI: 1396196440
Provider Name (Legal Business Name): MICHELLE L. VANDENTOORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2531
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-7104
  • Fax: 616-267-7594
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704278133
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704278133
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704278133
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number4704278133
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704278133
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: