Provider Demographics
NPI:1679192124
Name:DEMAAGD, EDWARD LAWRENCE (RN)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LAWRENCE
Last Name:DEMAAGD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 LUCAS DR SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2293
Mailing Address - Country:US
Mailing Address - Phone:616-633-3086
Mailing Address - Fax:
Practice Address - Street 1:4635 LUCAS DR SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2293
Practice Address - Country:US
Practice Address - Phone:616-633-3086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704300359163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health