Provider Demographics
NPI:1386783728
Name:ZYLSTRA, LIESL MARIE (CNP)
Entity type:Individual
Prefix:
First Name:LIESL
Middle Name:MARIE
Last Name:ZYLSTRA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1712
Mailing Address - Country:US
Mailing Address - Phone:269-948-8057
Mailing Address - Fax:269-948-8964
Practice Address - Street 1:1005 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1712
Practice Address - Country:US
Practice Address - Phone:269-948-8057
Practice Address - Fax:269-948-8964
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704182126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N36090002001Medicare ID - Type Unspecified