Healthcare Provider Details

I. General information

NPI: 1144745613
Provider Name (Legal Business Name): MEGAN ANN DEMAAGD-RODRIGUEZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN ANN DEMAAGD

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 LAFAYETTE AVE NE
GRAND RAPIDS MI
49505-5092
US

IV. Provider business mailing address

256 PROSPECT AVE SE APT 2
GRAND RAPIDS MI
49503-4619
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-8800
  • Fax:
Mailing address:
  • Phone: 616-566-3235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704308193
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: