Basic Information
| Provider Information | |||||||||
| NPI: | 1538551429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOELMAN | ||||||||
| FirstName: | KATIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 BALL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566571 | ||||||||
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| Practice Location | |||||||||
| Address1: | 285 MANZANA CT NW APT 3C | ||||||||
| Address2: | |||||||||
| City: | WALKER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495347144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163375962 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2015 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | 0 | 05 | MI | MEDICAID |