1902932403 NPI number — DR. KRISTINE MARIE VAZZANO PHD

Table of content: DR. KRISTINE MARIE VAZZANO PHD (NPI 1902932403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902932403 NPI number — DR. KRISTINE MARIE VAZZANO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAZZANO
Provider First Name:
KRISTINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TIPPEN
Provider Other First Name:
KRISTINE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902932403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3910 TELEGRAPH RD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-1420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-686-0346
Provider Business Mailing Address Fax Number:
248-686-0344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3910 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48302-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-686-0346
Provider Business Practice Location Address Fax Number:
248-686-0344
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  6301014012 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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