Provider Demographics
NPI:1427381623
Name:VANDENBERG, BRIAN KEITH (ARNP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14073 STATE HIGHWAY NN
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-8329
Mailing Address - Country:US
Mailing Address - Phone:805-403-7075
Mailing Address - Fax:
Practice Address - Street 1:14073 STATE HIGHWAY NN
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-8329
Practice Address - Country:US
Practice Address - Phone:805-403-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2022-02-21
Deactivation Date:2020-11-21
Deactivation Code:
Reactivation Date:2021-03-08
Provider Licenses
StateLicense IDTaxonomies
332BN1400X
KS139604363L00000X
KS5374997032363LF0000X
MO1427381623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner