Provider Demographics
NPI:1104276948
Name:VANDEWALLE, ALICIA ANNE (APRN)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANNE
Last Name:VANDEWALLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:ANNE
Other - Last Name:MAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:402 N MAPLE
Mailing Address - City:OSMOND
Mailing Address - State:NE
Mailing Address - Zip Code:68765-0429
Mailing Address - Country:US
Mailing Address - Phone:402-748-3393
Mailing Address - Fax:
Practice Address - Street 1:106 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NE
Practice Address - Zip Code:68771-5300
Practice Address - Country:US
Practice Address - Phone:402-337-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily