Healthcare Provider Details

I. General information

NPI: 1932654811
Provider Name (Legal Business Name): JESSICA VETTRAINO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 BARRINGTON RD
BLOOMFIELD HILLS MI
48302-0600
US

IV. Provider business mailing address

96 BARRINGTON RD
BLOOMFIELD HILLS MI
48302-0600
US

V. Phone/Fax

Practice location:
  • Phone: 248-770-4417
  • Fax:
Mailing address:
  • Phone: 248-770-4417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704281372
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704281372
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: