Provider Demographics
NPI:1083328710
Name:VANDENBROUCKE, MARY JOANNE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOANNE
Last Name:VANDENBROUCKE
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 1:11221 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-6935
Mailing Address - Country:US
Mailing Address - Phone:402-332-5578
Mailing Address - Fax:
Practice Address - Street 1:11221 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-6935
Practice Address - Country:US
Practice Address - Phone:402-332-5578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant