Basic Information
| Provider Information | |||||||||
| NPI: | 1558619536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHIPPONERI | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVANDUSKI | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 47601 GRAND RIVER AVE STE B229 | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483741257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484654290 | ||||||||
| FaxNumber: | 2484654883 | ||||||||
| Practice Location | |||||||||
| Address1: | 47601 GRAND RIVER AVE STE B229 | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483741257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484654290 | ||||||||
| FaxNumber: | 2484654883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9383489 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4704316428 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1558619536 | 05 | MI | MEDICAID | 1532143 | 05 | TN | MEDICAID | 6000643 | 01 | TN | BLUE CROSS-BLUE SHIELD | OTHER | P01309140 | 01 | TN | RR MEDICARE | OTHER |