Provider Demographics
NPI:1982107140
Name:ELAN VITALE HEALTHY LIVING SOLUTIONS
Entity Type:Organization
Organization Name:ELAN VITALE HEALTHY LIVING SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:248-667-2531
Mailing Address - Street 1:27247 JOY RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27247 JOY RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1022
Practice Address - Country:US
Practice Address - Phone:248-667-6307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704170920363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty