Provider Demographics
NPI:1558744797
Name:VANDERWEIDE, CLARA
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:VANDERWEIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLARA
Other - Middle Name:
Other - Last Name:DEJONGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 GRANDVILLE AVE SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4920
Practice Address - Country:US
Practice Address - Phone:616-685-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293832363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily