Provider Demographics
NPI:1750408688
Name:VANDYKE, JUDY K (CNP)
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:K
Last Name:VANDYKE
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 1:1 HURLEY PLZ
Mailing Address - Street 2:5TH FLOOR S.O.N.
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5902
Mailing Address - Country:US
Mailing Address - Phone:810-762-7038
Mailing Address - Fax:810-760-0440
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9353
Practice Address - Fax:810-262-9187
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704133863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B51149OtherBLUE SHIELD
MI4130451Medicaid
MI0B51149OtherBLUE SHIELD
MI4130451Medicaid