Healthcare Provider Details

I. General information

NPI: 1962789560
Provider Name (Legal Business Name): JACQUELYN SUE KIEFER PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 WASHINGTON AVE
HOLLAND MI
49423-7725
US

IV. Provider business mailing address

926 WASHINGTON AVE
HOLLAND MI
49423-7725
US

V. Phone/Fax

Practice location:
  • Phone: 616-393-0166
  • Fax: 616-393-0167
Mailing address:
  • Phone: 616-393-0166
  • Fax: 616-393-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704162589
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: