Basic Information
| Provider Information | |||||||||
| NPI: | 1992292353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VLIET | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3955 PATIENT CARE DR STE A | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173747600 | ||||||||
| FaxNumber: | 8554955457 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 S PUTNAM ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488951623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176553515 | ||||||||
| FaxNumber: | 8554760189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2018 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704273069 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.