MEDICARE: MRS. VICKI RUPERT WHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	4704203400	MI

General Provider Information

NPI Number	:	1336536309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICKI RUPERT WHNP-BC

Provider Business Mailing Address
First Line	:	14700 LAKE SHORE DR
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-1931
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14651 W UPRIGHT ST
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-1266
Country	:	US
Telephone Number	:	231-547-4477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2015
Last Update Date	:	04/17/2015

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