Healthcare Provider Details

I. General information

NPI: 1760066716
Provider Name (Legal Business Name): MS. BRIANNA MARIE VULTAGGIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 06/29/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49970 VAN DYKE AVE
SHELBY TOWNSHIP MI
48317-1347
US

IV. Provider business mailing address

51145 NICOLETTE DR
CHESTERFIELD MI
48047-4585
US

V. Phone/Fax

Practice location:
  • Phone: 586-991-6596
  • Fax: 248-712-4381
Mailing address:
  • Phone: 586-228-9991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: