Provider Demographics
NPI:1023233806
Name:VANDERGAAST, DEBORAH LORRAINE (RN)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:LORRAINE
Last Name:VANDERGAAST
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PARKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772-1349
Mailing Address - Country:US
Mailing Address - Phone:563-886-3143
Mailing Address - Fax:563-886-3143
Practice Address - Street 1:118 PARKVIEW CT
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IA
Practice Address - Zip Code:52772-1349
Practice Address - Country:US
Practice Address - Phone:563-886-3143
Practice Address - Fax:563-886-3143
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA104423163W00000X, 385HR2060X, 385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Not Answered385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0453555Medicaid
IA3816058OtherTITLE XX CHILD CARE ASSIS