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General NPI Number Information
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NPI Number | 1790019222
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Entity Type | Individual
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Provider Name | MRS. STACIE DAWN VANDERVER
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Gender | Female
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Dates
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Enumeration Date | 09/30/2009
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Last Update Date | 09/30/2009
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Provider Practice Location Address
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Address Line | 2850 S INDUSTRIAL HWY SPC 5758
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City | ANN ARBOR
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State | MI
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Zip | 48104-6796
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Country | US
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Telephone | 734-477-7298
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Fax | 734-998-2369
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Provider Business Mailing Address
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Address Line | 2850 S INDUSTRIAL HWY SPC 5758
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City | ANN ARBOR
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State | MI
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Zip | 48104-6796
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0200X
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Taxonomy Name | Pediatric Registered Nurse
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License Number | 4704254099
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License Number State | MI
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