Provider Demographics
NPI:1205337219
Name:VERGILIO-PANEK, LINDA A (CNP)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:A
Last Name:VERGILIO-PANEK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50583 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1269
Mailing Address - Country:US
Mailing Address - Phone:313-282-8811
Mailing Address - Fax:
Practice Address - Street 1:50583 PRINCETON DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1269
Practice Address - Country:US
Practice Address - Phone:313-282-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
MI4704160638363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care