Provider Demographics
NPI:1558475244
Name:VANDEUSEN, CYNTHIA DIANE (FNP ; GNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANE
Last Name:VANDEUSEN
Suffix:
Gender:F
Credentials:FNP ; GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63314
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3314
Mailing Address - Country:US
Mailing Address - Phone:828-696-1312
Mailing Address - Fax:828-696-1314
Practice Address - Street 1:709 N JUSTICE ST
Practice Address - Street 2:SUITE B
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3454
Practice Address - Country:US
Practice Address - Phone:828-696-1234
Practice Address - Fax:828-696-1257
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501592363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000776Medicaid
NCS90041Medicare UPIN
NC7000776Medicaid