Provider Demographics
NPI:1790723260
Name:VANDERGRIFT, DELORES A (FNP)
Entity Type:Individual
Prefix:
First Name:DELORES
Middle Name:A
Last Name:VANDERGRIFT
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 1:2425 FAIRLAWN DR
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-3517
Mailing Address - Country:US
Mailing Address - Phone:417-237-0604
Mailing Address - Fax:417-237-0613
Practice Address - Street 1:2425 FAIRLAWN DR
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-3517
Practice Address - Country:US
Practice Address - Phone:417-237-0604
Practice Address - Fax:417-237-0613
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO079678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790723260Medicaid
MO1790723260Medicaid
MO501150063Medicare PIN
S37220Medicare UPIN