Provider Demographics
NPI:1467905133
Name:REBANDT, TIFFANY D (ANP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:D
Last Name:REBANDT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:D
Other - Last Name:KUIPERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:310 LAFAYETTE AVE SE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-752-6832
Mailing Address - Fax:616-732-8902
Practice Address - Street 1:310 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 400
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-752-6832
Practice Address - Fax:616-732-8902
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293043363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health