Provider Demographics
NPI:1801614656
Name:VANDERVELDE, MACKENZIE LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LAUREN
Last Name:VANDERVELDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 KENMOOR AVE SE STE 201
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8604
Mailing Address - Country:US
Mailing Address - Phone:616-920-0825
Mailing Address - Fax:
Practice Address - Street 1:655 KENMOOR AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8604
Practice Address - Country:US
Practice Address - Phone:616-920-0825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601012783363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant