Provider Demographics
NPI:1669847067
Name:VANDEWATER, BRENDA LYNN
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:VANDEWATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LYNN
Other - Last Name:MCCLURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:12349 ERSKINE RD
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-7508
Mailing Address - Country:US
Mailing Address - Phone:605-745-8910
Mailing Address - Fax:605-745-7654
Practice Address - Street 1:1201 HIGHWAY 71 S
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-8800
Practice Address - Country:US
Practice Address - Phone:605-745-8910
Practice Address - Fax:605-745-7654
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001015363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily