Provider Demographics
NPI:1336211762
Name:VANLOAN, JENNIFER RAE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:VANLOAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8744 MUSGROVE HWY
Mailing Address - Street 2:
Mailing Address - City:SUNFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48890-9797
Mailing Address - Country:US
Mailing Address - Phone:206-595-5001
Mailing Address - Fax:
Practice Address - Street 1:107 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SARANAC
Practice Address - State:MI
Practice Address - Zip Code:48881-5121
Practice Address - Country:US
Practice Address - Phone:616-642-9408
Practice Address - Fax:616-642-6940
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254772163W00000X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid
MI0M78350Medicare PIN