Healthcare Provider Details

I. General information

NPI: 1699315747
Provider Name (Legal Business Name): KEVIN HENGEVELD DNP, RN, A-GNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE STE 2045
GRAND RAPIDS MI
49503-4692
US

IV. Provider business mailing address

300 LAFAYETTE AVE SE STE 2045
GRAND RAPIDS MI
49503-4692
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-3098
  • Fax: 616-685-3095
Mailing address:
  • Phone: 616-685-3098
  • Fax: 616-685-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704207506
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: