Healthcare Provider Details

I. General information

NPI: 1548043128
Provider Name (Legal Business Name): MARIE LYNNE VAN TIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/20/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 SANDY RUN DR
HOLLAND MI
49424-5310
US

IV. Provider business mailing address

1363 SANDY RUN DR
HOLLAND MI
49424-5310
US

V. Phone/Fax

Practice location:
  • Phone: 616-566-9779
  • Fax:
Mailing address:
  • Phone: 616-566-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704308724
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number359141
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: