Provider Demographics
NPI:1740524594
Name:LELLI, VANESSA RAE
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:RAE
Last Name:LELLI
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 1:30920 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-7738
Mailing Address - Country:US
Mailing Address - Phone:734-431-7908
Mailing Address - Fax:
Practice Address - Street 1:30920 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-7738
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-18
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN680698363LF0000X
PASP016058363LF0000X
OHRN.355324363LF0000X
OHAPRN.CNP.14347363LF0000X
MI4704272577363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily