Provider Demographics
NPI:1891256020
Name:VANDER WAL, ALICIA KAY (RN)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:KAY
Last Name:VANDER WAL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4368 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-9459
Mailing Address - Country:US
Mailing Address - Phone:616-848-0402
Mailing Address - Fax:
Practice Address - Street 1:1015 W LAWRENCE AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5017
Practice Address - Country:US
Practice Address - Phone:773-751-1731
Practice Address - Fax:773-275-3695
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704315107163W00000X
IL041478493163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse