Basic Information
| Provider Information | |||||||||
| NPI: | 1972687978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLDEJANS | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 476 RIVERWALK DR | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488549381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179994500 | ||||||||
| FaxNumber: | 5179994510 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 JOLLY RD | ||||||||
| Address2: | STE B | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173474085 | ||||||||
| FaxNumber: | 5173474170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | APRN11008849 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 4704135672 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2200X | 4704135672 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.