Provider Demographics
NPI:1053784884
Name:VANLUE, STACEY
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:VANLUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22721 DIAMOND COVE ST
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9711
Mailing Address - Country:US
Mailing Address - Phone:269-445-9355
Mailing Address - Fax:
Practice Address - Street 1:22721 DIAMOND COVE ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9711
Practice Address - Country:US
Practice Address - Phone:269-445-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902015195124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist