Provider Demographics
NPI:1124043492
Name:MULDER, ELIZABETH JOY (ANP)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JOY
Last Name:MULDER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-392-8035
Mailing Address - Fax:616-393-4740
Practice Address - Street 1:904 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7724
Practice Address - Country:US
Practice Address - Phone:616-392-8035
Practice Address - Fax:616-393-4740
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704146775363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS98726Medicare UPIN
MIG06011015Medicare ID - Type UnspecifiedMEDICARE NUMBER