Provider Demographics
NPI:1790019222
Name:VANDERVER, STACIE DAWN
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:DAWN
Last Name:VANDERVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 S INDUSTRIAL HWY SPC 5758
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2850 S INDUSTRIAL HWY SPC 5758
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6796
Practice Address - Country:US
Practice Address - Phone:734-477-7298
Practice Address - Fax:734-998-2369
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254099163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI46848699Medicaid