MEDICARE: MARILYN LOUISE VANTASSEL RN, NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	4704125395	MI

General Provider Information

NPI Number	:	1942573787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN LOUISE VANTASSEL RN, NP

Provider Business Mailing Address
First Line	:	3150 LIVERNOIS RD
Second Line	:	SUITE 170
City	:	TROY
State	:	MI
Zip	:	48083-5031
Country	:	US
Telephone Number	:	888-315-5442
Fax Number	:

Provider Business Practice Location Address
First Line	:	3150 LIVERNOIS RD
Second Line	:	SUITE 170
City	:	TROY
State	:	MI
Zip	:	48083-5031
Country	:	US
Telephone Number	:	888-315-5442
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	02/09/2012

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