Provider Demographics
NPI:1922089804
Name:VANDEVELDE, JOHN DANIEL (PNP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DANIEL
Last Name:VANDEVELDE
Suffix:
Gender:M
Credentials:PNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:1261 VISCAYA PKWY STE 101
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3252
Practice Address - Country:US
Practice Address - Phone:239-573-7337
Practice Address - Fax:239-574-5883
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9455776363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBMBUOOtherFLORIDA BLUE
FL020729900Medicaid