Provider Demographics
NPI:1063058345
Name:VAN ALLSBURG, KATELYN (NP-C)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:VAN ALLSBURG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 OTTAWA AVE NW APT 621
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2766
Mailing Address - Country:US
Mailing Address - Phone:616-340-0547
Mailing Address - Fax:
Practice Address - Street 1:250 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4608
Practice Address - Country:US
Practice Address - Phone:616-685-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285652363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner