Basic Information
| Provider Information | |||||||||
| NPI: | 1649715236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDONGEN-TRIMMER | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DRIVE | ||||||||
| Address2: | 7TH FLOOR MED SUBSPECIALTY CLINIC | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481094257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349369814 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2017 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 231051-30 | WI | N | Nursing Service Providers | Registered Nurse | 163W00000X | 4704296190 | MI | N | Nursing Service Providers | Registered Nurse | 363L00000X | 4704296190 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 7264-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 4704296190 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1649715236 | 05 | WI | MEDICAID |