Provider Demographics
NPI:1942573787
Name:VANTASSEL, MARILYN LOUISE (RN, NP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:LOUISE
Last Name:VANTASSEL
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 LIVERNOIS RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5031
Mailing Address - Country:US
Mailing Address - Phone:888-315-5442
Mailing Address - Fax:
Practice Address - Street 1:3150 LIVERNOIS RD
Practice Address - Street 2:SUITE 170
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5031
Practice Address - Country:US
Practice Address - Phone:888-315-5442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704125395363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health