Provider Demographics
NPI:1194122937
Name:VASSALLO, PATRICIA (CPNP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48353 COMMONVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-2772
Mailing Address - Country:US
Mailing Address - Phone:248-961-4371
Mailing Address - Fax:
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:PB 2 SUITE 209
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-3978
Practice Address - Fax:313-417-2730
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704268599363LP0200X
PASP027691363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H208910OtherBLUE CROSS