Provider Demographics
NPI:1326662065
Name:DOTY, VANESSA (NP-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DOTY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
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 1:588 E LAKEWOOD BLVD FL 1
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2023
Practice Address - Country:US
Practice Address - Phone:616-494-5840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308578363LP0200X, 363LP0200X
MT178737363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics