Provider Demographics
NPI:1386925410
Name:VARGHESE, MINI (NP)
Entity type:Individual
Prefix:MRS
First Name:MINI
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:MINI
Other - Middle Name:
Other - Last Name:MARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:391 TANNER DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-4714
Mailing Address - Country:US
Mailing Address - Phone:248-250-6454
Mailing Address - Fax:
Practice Address - Street 1:391 TANNER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-4714
Practice Address - Country:US
Practice Address - Phone:248-250-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704223519163W00000X, 363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care