Healthcare Provider Details

I. General information

NPI: 1508508953
Provider Name (Legal Business Name): LAUREN VACHON AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 SHELDON AVE SE
GRAND RAPIDS MI
49503-4234
US

IV. Provider business mailing address

5073 WALLINGFORD DR NW
COMSTOCK PARK MI
49321-9314
US

V. Phone/Fax

Practice location:
  • Phone: 616-331-9830
  • Fax: 616-331-9831
Mailing address:
  • Phone: 313-269-5961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1518019223
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: