Provider Demographics
NPI:1982048187
Name:VONDER HEIDE, MARILYN TINA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:TINA
Last Name:VONDER HEIDE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 PINECROFT LN SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4927
Mailing Address - Country:US
Mailing Address - Phone:616-532-3124
Mailing Address - Fax:
Practice Address - Street 1:1775 PINECROFT LN SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4927
Practice Address - Country:US
Practice Address - Phone:616-532-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704164450163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse