Healthcare Provider Details

I. General information

NPI: 1407508781
Provider Name (Legal Business Name): HEATHER WILSON-VANI RN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 MILITARY ST
PORT HURON MI
48060-5416
US

IV. Provider business mailing address

1011 MILITARY ST
PORT HURON MI
48060-5416
US

V. Phone/Fax

Practice location:
  • Phone: 810-488-8000
  • Fax: 810-488-8005
Mailing address:
  • Phone: 810-488-8000
  • Fax: 810-488-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704369758
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704369758
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: