Healthcare Provider Details

I. General information

NPI: 1437080801
Provider Name (Legal Business Name): VICTORIA LYN VANDER VELDE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S TELEGRAPH RD
BLOOMFIELD HILLS MI
48302-0286
US

IV. Provider business mailing address

2525 S TELEGRAPH RD
BLOOMFIELD HILLS MI
48302-0286
US

V. Phone/Fax

Practice location:
  • Phone: 248-933-7017
  • Fax:
Mailing address:
  • Phone: 248-933-7017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601014182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: