Provider Demographics
NPI:1215203047
Name:MAYWORTH, VANDY NICHOLE (ARNP)
Entity Type:Individual
Prefix:
First Name:VANDY
Middle Name:NICHOLE
Last Name:MAYWORTH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 SUN N LAKE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-1944
Mailing Address - Country:US
Mailing Address - Phone:863-402-2229
Mailing Address - Fax:863-402-1209
Practice Address - Street 1:4240 SUN N LAKE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1944
Practice Address - Country:US
Practice Address - Phone:863-402-2229
Practice Address - Fax:863-402-1209
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9270201363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004721800Medicaid
FLFY414YMedicare UPIN
FLFY414ZMedicare UPIN