Provider Demographics
NPI:1508531088
Name:BAUSWELL, KIVA DA-SHAN (A-GNP)
Entity Type:Individual
Prefix:
First Name:KIVA
Middle Name:DA-SHAN
Last Name:BAUSWELL
Suffix:
Gender:F
Credentials:A-GNP
Other - Prefix:
Other - First Name:KIVA
Other - Middle Name:DA-SHAN
Other - Last Name:BAUSWELL-HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:A-GNP
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:
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:2021-08-16
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291746363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology