Provider Demographics
NPI:1477204394
Name:VANDENBERG, AMY SUE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12409 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-8826
Mailing Address - Country:US
Mailing Address - Phone:616-893-8403
Mailing Address - Fax:
Practice Address - Street 1:521 E MICHIGAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3889
Practice Address - Country:US
Practice Address - Phone:269-349-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704212043363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily