Provider Demographics
NPI:1366029241
Name:VANDEVANDER, FREDA
Entity Type:Individual
Prefix:
First Name:FREDA
Middle Name:
Last Name:VANDEVANDER
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 1:6324 MOUNT FREEDOM DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26804-7516
Mailing Address - Country:US
Mailing Address - Phone:304-567-2442
Mailing Address - Fax:
Practice Address - Street 1:1408 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3325
Practice Address - Country:US
Practice Address - Phone:304-636-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant