Provider Demographics
NPI:1043800170
Name:VANDERHULST, BRADLEY ALLEN (LPN)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:ALLEN
Last Name:VANDERHULST
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 WOLF RIVER CT NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-3460
Mailing Address - Country:US
Mailing Address - Phone:616-644-2084
Mailing Address - Fax:
Practice Address - Street 1:1713 7TH ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2426
Practice Address - Country:US
Practice Address - Phone:231-726-1214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111898164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703111898OtherLARA