Provider Demographics
NPI:1275198533
Name:DEWILDT, AUBREY ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:ELIZABETH
Last Name:DEWILDT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AUBREY
Other - Middle Name:ELIZABETH
Other - Last Name:DWYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:
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 1:145 MICHIGAN ST NE STE 3410
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2563
Practice Address - Country:US
Practice Address - Phone:616-391-9945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307498363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner