Provider Demographics
NPI:1093002909
Name:VANDUSEN, KIMBERLY AMICK (MS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:AMICK
Last Name:VANDUSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-1924
Mailing Address - Country:US
Mailing Address - Phone:540-230-2246
Mailing Address - Fax:
Practice Address - Street 1:1915 HOLLY ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37206
Practice Address - Country:US
Practice Address - Phone:540-230-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1203011235Z00000X
TN4755235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist