Provider Demographics
NPI:1417326018
Name:SAMUEL, CAROLYN (NP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:JEAN
Other - Last Name:WHAITE
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:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:8333 FELCH STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2602
Practice Address - Country:US
Practice Address - Phone:616-748-2850
Practice Address - Fax:616-748-2855
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272559363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner