Provider Demographics
NPI:1902567613
Name:MIEDEMA- WESTRA, KENNEDY LEIGH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KENNEDY
Middle Name:LEIGH
Last Name:MIEDEMA- WESTRA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:KENNEDY
Other - Middle Name:
Other - Last Name:MIEDEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15100 WHITTAKER WAY
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8696
Practice Address - Country:US
Practice Address - Phone:949-268-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704351739363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily