Provider Demographics
NPI:1114395803
Name:LEDESMA, LUCY (NP)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:LEDESMA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 LAFAYETTE AVE SE
Practice Address - Street 2:STE 410
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4693
Practice Address - Country:US
Practice Address - Phone:616-685-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704232926363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health