Provider Demographics
NPI:1144825530
Name:VIDANA, LIZ KIMBERLY (RN)
Entity type:Individual
Prefix:
First Name:LIZ KIMBERLY
Middle Name:
Last Name:VIDANA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:VIDANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1983 SPRUCEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5867
Mailing Address - Country:US
Mailing Address - Phone:248-797-4536
Mailing Address - Fax:
Practice Address - Street 1:1983 SPRUCEWOOD DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5867
Practice Address - Country:US
Practice Address - Phone:248-797-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704363223163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management