Provider Demographics
NPI:1457324576
Name:VANEKEN, MIA LYNNE (DO)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:LYNNE
Last Name:VANEKEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 S. VAL VISTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7309
Mailing Address - Country:US
Mailing Address - Phone:480-782-0993
Mailing Address - Fax:855-329-8939
Practice Address - Street 1:3815 S. VAL VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7309
Practice Address - Country:US
Practice Address - Phone:480-782-0993
Practice Address - Fax:855-329-8939
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3984207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872532Medicaid
AZH71493Medicare UPIN
AZ80000Medicare ID - Type Unspecified