Provider Demographics
NPI:1407215189
Name:VANDERMARK, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:VANDERMARK
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 1:25 WHITNEY DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-8402
Mailing Address - Country:US
Mailing Address - Phone:513-969-8768
Mailing Address - Fax:
Practice Address - Street 1:25 WHITNEY DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-8402
Practice Address - Country:US
Practice Address - Phone:513-969-8768
Practice Address - Fax:937-258-4261
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN153433-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse