Provider Demographics
NPI:1255908976
Name:VANDERKAMP, ELYSE
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:VANDERKAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8699 FLAT CREEK DR UNIT I
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8944
Mailing Address - Country:US
Mailing Address - Phone:616-438-2371
Mailing Address - Fax:
Practice Address - Street 1:1401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1486
Practice Address - Country:US
Practice Address - Phone:231-924-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010192222251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic