Healthcare Provider Details

I. General information

NPI: 1821466368
Provider Name (Legal Business Name): VY THUY THAN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 JOLLY RD STE B
OKEMOS MI
48864-3983
US

IV. Provider business mailing address

PO BOX 639295 DEPT 93394
CINCINNATI OH
45263-9295
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-4085
  • Fax:
Mailing address:
  • Phone: 248-266-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704282499
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704282499
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704282499
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: