Basic Information
| Provider Information | |||||||||
| NPI: | 1306391339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEERINGA | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLACE | ||||||||
| OtherFirstName: | ERIN | ||||||||
| OtherMiddleName: | TAYLOR | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
| FaxNumber: | 6164866702 | ||||||||
| Practice Location | |||||||||
| Address1: | 3152 PORT SHELDON ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | HUDSONVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494269297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166699238 | ||||||||
| FaxNumber: | 6166698296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2016 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704318332 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.