Provider Demographics
NPI:1891772885
Name:VANDERGRIFF, JOANN MCCULLAR (MSN, FNP)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:MCCULLAR
Last Name:VANDERGRIFF
Suffix:
Gender:F
Credentials:MSN, FNP
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 1382
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88221-1382
Mailing Address - Country:US
Mailing Address - Phone:505-887-4073
Mailing Address - Fax:505-887-1000
Practice Address - Street 1:2430 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3553
Practice Address - Country:US
Practice Address - Phone:505-887-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2007-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR35927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR01504Medicare UPIN