Provider Demographics
NPI:1992783906
Name:VILLASENOR, SALLY (NP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:VILLASENOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR STE J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:4200 WHITEHALL DR STE 150
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9694
Practice Address - Country:US
Practice Address - Phone:734-995-0308
Practice Address - Fax:734-995-0425
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210404363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4639786Medicaid
MI11-4939817Medicaid
MI10-4639795Medicaid
MI11-4939782Medicaid
MI10-4639777Medicaid
MI11-4939791Medicaid
MI10-4639801Medicaid
MI11-4939826Medicaid
MIN51160039Medicare ID - Type UnspecifiedPEC OKW
MI10-4639801Medicaid
MI10-4639795Medicaid