Provider Demographics
NPI:1881193639
Name:KINGSBURY, ANDREW (NP)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:KINGSBURY
Suffix:
Gender:M
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 # 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:
Mailing Address - Fax:
Practice Address - Street 1:9090 S RODGERS CT SE STE A
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8052
Practice Address - Country:US
Practice Address - Phone:616-891-0422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276179363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner