Provider Demographics
NPI:1467923375
Name:VANDER WOUDE, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:VANDER WOUDE
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 1:509 SHAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-1652
Mailing Address - Country:US
Mailing Address - Phone:219-680-9027
Mailing Address - Fax:
Practice Address - Street 1:801 MACARTHUR BLVD.
Practice Address - Street 2:SUITE 304
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-836-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28180656A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily