Provider Demographics
NPI:1730301672
Name:VANDYK, GRACE
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:
Last Name:VANDYK
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:PO BOX 1602
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470
Mailing Address - Country:US
Mailing Address - Phone:561-795-9087
Mailing Address - Fax:561-795-4036
Practice Address - Street 1:3347 STATE ROAD 7
Practice Address - Street 2:STE 200
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8095
Practice Address - Country:US
Practice Address - Phone:561-795-9087
Practice Address - Fax:561-795-4036
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1704182363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS72310Medicare UPIN