Provider Demographics
NPI:1861903072
Name:VANDRIEL, COURTNEY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:VANDRIEL
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2447 UNION AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5161 NORTHLAND DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1015
Practice Address - Country:US
Practice Address - Phone:616-498-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-14
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293590163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty