Provider Demographics
NPI:1710224019
Name:VAN TIL, KATHLEEN SUE (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUE
Last Name:VAN TIL
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
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 1:588 E LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2023
Practice Address - Country:US
Practice Address - Phone:616-494-5810
Practice Address - Fax:616-494-5901
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704151536363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily