Provider Demographics
NPI:1841849544
Name:VANDERPOOL, IMAOBONG IBOKETTE (NP)
Entity type:Individual
Prefix:
First Name:IMAOBONG
Middle Name:IBOKETTE
Last Name:VANDERPOOL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17256 ROSELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2823
Mailing Address - Country:US
Mailing Address - Phone:248-388-0881
Mailing Address - Fax:
Practice Address - Street 1:17256 ROSELAND BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2823
Practice Address - Country:US
Practice Address - Phone:248-388-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313471363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care