Provider Demographics
NPI:1447611082
Name:VERDUSCO, JULIE ANNE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANNE
Last Name:VERDUSCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANNE
Other - Last Name:VANDERMALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 S STATE ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1549
Practice Address - Country:US
Practice Address - Phone:616-887-5989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant