Provider Demographics
NPI:1508092354
Name:VANDER WAL, MARY CAROL (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:VANDER WAL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13712 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:MARNE
Mailing Address - State:MI
Mailing Address - Zip Code:49435-9727
Mailing Address - Country:US
Mailing Address - Phone:616-677-3633
Mailing Address - Fax:616-677-5330
Practice Address - Street 1:13712 32ND AVE
Practice Address - Street 2:
Practice Address - City:MARNE
Practice Address - State:MI
Practice Address - Zip Code:49435-9727
Practice Address - Country:US
Practice Address - Phone:616-677-3633
Practice Address - Fax:616-677-5330
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704118232363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily