Provider Demographics
NPI:1306486881
Name:EDELBLUT, KADENCE
Entity type:Individual
Prefix:
First Name:KADENCE
Middle Name:
Last Name:EDELBLUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1614
Mailing Address - Country:US
Mailing Address - Phone:616-502-5940
Mailing Address - Fax:
Practice Address - Street 1:131 W SEAWAY DR
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3759
Practice Address - Country:US
Practice Address - Phone:231-375-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009749363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical