Provider Demographics
NPI:1467161471
Name:VANDERTOL, LISA JOY (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JOY
Last Name:VANDERTOL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13907 DELTA DR
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9574
Mailing Address - Country:US
Mailing Address - Phone:231-250-3316
Mailing Address - Fax:
Practice Address - Street 1:4473 220TH AVE
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-8593
Practice Address - Country:US
Practice Address - Phone:231-832-2247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704270281163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse