Provider Demographics
NPI:1861153736
Name:DATEMA, LAURA A (CNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:DATEMA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:ODDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
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:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 4200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2559
Practice Address - Country:US
Practice Address - Phone:616-267-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286319363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner