Provider Demographics
NPI:1407180755
Name:PROCTOR, YVETTE (LPN)
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 PRODUCT DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3807
Mailing Address - Country:US
Mailing Address - Phone:248-844-9650
Mailing Address - Fax:
Practice Address - Street 1:2619 PRODUCT DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3807
Practice Address - Country:US
Practice Address - Phone:248-844-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703089833164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2223170Medicaid