Provider Demographics
NPI:1255461687
Name:TENEYCK, CAROL IRENE (NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:IRENE
Last Name:TENEYCK
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:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-774-2822
Mailing Address - Fax:616-391-8665
Practice Address - Street 1:230 MICHIGAN ST NE
Practice Address - Street 2:SUITE 230
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2550
Practice Address - Country:US
Practice Address - Phone:616-774-2822
Practice Address - Fax:616-391-8665
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704119230163W00000X, 363L00000X, 364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500D111930 / 876270OtherBCBSM
MI4984741Medicaid
MI500D111930 / 876270OtherBCBSM
MI4984741Medicaid