Provider Demographics
NPI:1023557634
Name:ANTHONY, ALIA
Entity Type:Individual
Prefix:
First Name:ALIA
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALIA
Other - Middle Name:
Other - Last Name:ANSELMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1108 W STATE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9711
Practice Address - Country:US
Practice Address - Phone:269-945-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291894363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner