Provider Demographics
NPI:1043562085
Name:VITANOVSKI-PETROVSKI, DANA (NP)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:VITANOVSKI-PETROVSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:
Other - Last Name:VITANOVSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15959 HALL RD STE 100
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5364
Practice Address - Country:US
Practice Address - Phone:586-416-5940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269062163W00000X, 363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F38769OtherBCBSM GROUP NP PIN
MI0861925OtherBCBSM PIN
MI0F37550OtherBCBSM GROUP PIN
MI1043562085Medicaid
MI0F38769OtherBCBSM GROUP NP PIN