Provider Demographics
NPI:1568094340
Name:VANWASSHNOVA, TAMORA (FNP)
Entity Type:Individual
Prefix:
First Name:TAMORA
Middle Name:
Last Name:VANWASSHNOVA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:13697 15 MILE RD
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-8533
Practice Address - Country:US
Practice Address - Phone:269-789-4905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206479363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily