Basic Information
| Provider Information | |||||||||
| NPI: | 1457324576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANEKEN | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 S. VAL VISTA DRIVE | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807820993 | ||||||||
| FaxNumber: | 8553298939 | ||||||||
| Practice Location | |||||||||
| Address1: | 3815 S. VAL VISTA DRIVE | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807820993 | ||||||||
| FaxNumber: | 8553298939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 05/30/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 3984 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VX0000X | 3984 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 872532 | 05 | AZ | MEDICAID |