Provider Demographics
NPI:1134230832
Name:VREEKE, TANYA L (DO)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:L
Last Name:VREEKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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 1:7782 20TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8524
Practice Address - Country:US
Practice Address - Phone:616-685-8700
Practice Address - Fax:616-457-5567
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020821207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA7177543Medicaid
IA7177543Medicaid
IAI6220Medicare ID - Type UnspecifiedDO