Provider Demographics
NPI:1669693446
Name:DEHAAN, PHYLLIS MARIE (NP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
Last Name:DEHAAN
Suffix:
Gender:F
Credentials:NP
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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:
Mailing Address - Fax:
Practice Address - Street 1:336 S RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3326
Practice Address - Country:US
Practice Address - Phone:616-394-3788
Practice Address - Fax:616-394-3796
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2016-05-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI47041008280363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN91970013Medicare PIN