Provider Demographics
NPI:1538116199
Name:WAALKES, ANNICA E (MD)
Entity Type:Individual
Prefix:
First Name:ANNICA
Middle Name:E
Last Name:WAALKES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
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 1:8333 FELCH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-9666
Practice Address - Country:US
Practice Address - Phone:616-772-4846
Practice Address - Fax:616-748-2855
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301087005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301087005OtherMD LICENSE
MI4301087005OtherMD LICENSE