Provider Demographics
NPI:1871023028
Name:VANDIVER, TAMARA NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:NICOLE
Last Name:VANDIVER
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 1:10422 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77705-8726
Mailing Address - Country:US
Mailing Address - Phone:409-673-8899
Mailing Address - Fax:
Practice Address - Street 1:2427 HWY 255 WEST
Practice Address - Street 2:
Practice Address - City:BROOKELAND
Practice Address - State:TX
Practice Address - Zip Code:75951
Practice Address - Country:US
Practice Address - Phone:409-698-9600
Practice Address - Fax:406-698-2800
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily