Healthcare Provider Details

I. General information

NPI: 1750408688
Provider Name (Legal Business Name): JUDY K. VANDYKE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HURLEY PLZ
FLINT MI
48503-5902
US

IV. Provider business mailing address

1 HURLEY PLZ 5TH FLOOR S.O.N.
FLINT MI
48503-5902
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-9353
  • Fax: 810-262-9187
Mailing address:
  • Phone: 810-762-7038
  • Fax: 810-760-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704133863
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: