Healthcare Provider Details

I. General information

NPI: 1508092354
Provider Name (Legal Business Name): MARY CAROL VANDER WAL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13712 32ND AVE
MARNE MI
49435-9727
US

IV. Provider business mailing address

13712 32ND AVE
MARNE MI
49435-9727
US

V. Phone/Fax

Practice location:
  • Phone: 616-677-3633
  • Fax: 616-677-5330
Mailing address:
  • Phone: 616-677-3633
  • Fax: 616-677-5330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704118232
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: