Provider Demographics
NPI:1083388615
Name:VANDEVENDER, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:VANDEVENDER
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:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:KERENS
Mailing Address - State:WV
Mailing Address - Zip Code:26276-0122
Mailing Address - Country:US
Mailing Address - Phone:304-376-6565
Mailing Address - Fax:
Practice Address - Street 1:615 VANDEVENDER HOLLOW RD.
Practice Address - Street 2:
Practice Address - City:KERENS
Practice Address - State:WV
Practice Address - Zip Code:26276-0122
Practice Address - Country:US
Practice Address - Phone:304-376-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant