Provider Demographics
NPI:1356457055
Name:VANDERLIST, JESSICA LYNN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:VANDERLIST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2628
Mailing Address - Country:US
Mailing Address - Phone:517-402-3773
Mailing Address - Fax:
Practice Address - Street 1:401 W GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2819
Practice Address - Country:US
Practice Address - Phone:517-975-7295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704221454367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered