Provider Demographics
NPI:1982976304
Name:TIMMER, ELLISON J (NP)
Entity type:Individual
Prefix:
First Name:ELLISON
Middle Name:J
Last Name:TIMMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELLISON
Other - Middle Name:J
Other - Last Name:KLAASEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5800 FOREMOST DR SE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7062
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:
Practice Address - Street 1:12460 RILEY ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8217
Practice Address - Country:US
Practice Address - Phone:616-399-6500
Practice Address - Fax:616-399-1908
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0871940OtherBCBSM PIN
MI1982976304Medicaid
MI1982976304Medicaid