Basic Information
Provider Information | |||||||||
NPI: | 1417326018 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAMUEL | ||||||||
FirstName: | CAROLYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHAITE | ||||||||
OtherFirstName: | CAROLYN | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495032560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6164866790 | ||||||||
FaxNumber: | 6164866702 | ||||||||
Practice Location | |||||||||
Address1: | 8333 FELCH STREET | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ZEELAND | ||||||||
State: | MI | ||||||||
PostalCode: | 494642602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6167482850 | ||||||||
FaxNumber: | 6167482855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2015 | ||||||||
LastUpdateDate: | 04/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704272559 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.