Provider Demographics
NPI:1962085860
Name:VAN DER PUYL, HOLLY A (NP-C)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:VAN DER PUYL
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 1:2109 HAMILTON RD STE 217
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1700
Mailing Address - Country:US
Mailing Address - Phone:517-580-0575
Mailing Address - Fax:
Practice Address - Street 1:2109 HAMILTON RD STE 217
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1700
Practice Address - Country:US
Practice Address - Phone:517-580-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269558363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology