Healthcare Provider Details

I. General information

NPI: 1447360433
Provider Name (Legal Business Name): SANDRA DEJONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8906 M 89
RICHLAND MI
49083
US

IV. Provider business mailing address

601 JOHN ST # 42
KALAMAZOO MI
49007-5341
US

V. Phone/Fax

Practice location:
  • Phone: 269-286-7130
  • Fax: 269-286-7131
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704214378
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: