Provider Demographics
NPI:1548043128
Name:VAN TIL, MARIE LYNNE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:LYNNE
Last Name:VAN TIL
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 1:1363 SANDY RUN DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-5310
Mailing Address - Country:US
Mailing Address - Phone:616-566-9779
Mailing Address - Fax:
Practice Address - Street 1:1363 SANDY RUN DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-5310
Practice Address - Country:US
Practice Address - Phone:616-566-9779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308724163WC0200X
NC359141163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine