MEDICARE: MRS. STACIE DAWN VANDERVER

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	163WP0200X	Pediatric Registered Nurse	4704254099	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790019222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACIE DAWN VANDERVER

Provider Business Mailing Address
First Line	:	2850 S INDUSTRIAL HWY SPC 5758
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-6796
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2850 S INDUSTRIAL HWY SPC 5758
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-6796
Country	:	US
Telephone Number	:	734-477-7298
Fax Number	:	734-998-2369

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

Provider Enumeration Date	:	09/30/2009
Last Update Date	:	09/30/2009

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