Provider Demographics
NPI:1730795485
Name:VAN ITTERSUM, ELYSE C (FNP-C)
Entity type:Individual
Prefix:MS
First Name:ELYSE
Middle Name:C
Last Name:VAN ITTERSUM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:C
Other - Last Name:REXER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6058 HEARTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5363
Mailing Address - Country:US
Mailing Address - Phone:248-765-6535
Mailing Address - Fax:
Practice Address - Street 1:4060 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-4923
Practice Address - Country:US
Practice Address - Phone:248-250-6420
Practice Address - Fax:248-250-6430
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704341270363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty