Provider Demographics
NPI:1316095342
Name:VANEENENAAM-IWANICKI, MARTHA SUE (ATC)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:SUE
Last Name:VANEENENAAM-IWANICKI
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:32347 OXFORD CT
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-2346
Mailing Address - Country:US
Mailing Address - Phone:586-415-0561
Mailing Address - Fax:586-415-1079
Practice Address - Street 1:FRASER HIGH SCHOOL
Practice Address - Street 2:34270 GARFIELD
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026
Practice Address - Country:US
Practice Address - Phone:586-879-2398
Practice Address - Fax:586-415-1079
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer