Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | TB009726 | MI |
NPI | 1003816224 |
---|---|
Provider Name | Tammy Born Huizenga |
First Address | Grand Rapids, MI 49512-9637 |
Second Address | Grand Rapids, MI 49512-9637 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2005 |
Last Update Date | 21/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E26816 | (02) | MI |