Provider Demographics
NPI:1144019134
Name:BOUWKNEGT, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BOUWKNEGT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9097 S THORNAPPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-8656
Mailing Address - Country:US
Mailing Address - Phone:231-414-4391
Mailing Address - Fax:
Practice Address - Street 1:725 FULLER AVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2105
Practice Address - Country:US
Practice Address - Phone:231-796-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI24291041001224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant