Healthcare Provider Details

I. General information

NPI: 1790019222
Provider Name (Legal Business Name): MRS. STACIE DAWN VANDERVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 S INDUSTRIAL HWY SPC 5758
ANN ARBOR MI
48104-6796
US

IV. Provider business mailing address

2850 S INDUSTRIAL HWY SPC 5758
ANN ARBOR MI
48104-6796
US

V. Phone/Fax

Practice location:
  • Phone: 734-477-7298
  • Fax: 734-998-2369
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number4704254099
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: