=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124337860
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAUREEN ANN VANTINE ANP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2010
-----------------------------------------------------
Last Update Date | 08/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 RENAISSANCE CTR STE 2600
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48243-1599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-731-8994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 RENAISSANCE CTR STE 2600
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48243-1599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-731-8994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | CNP4160
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | COA.11871-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------