Provider Demographics
NPI:1295123446
Name:VANCAMP, MARIE (DNP, PMHNP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:VANCAMP
Suffix:
Gender:F
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:GORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4310 METRO PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9416
Mailing Address - Country:US
Mailing Address - Phone:239-223-2751
Mailing Address - Fax:
Practice Address - Street 1:4310 METRO PKWY STE 205
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9416
Practice Address - Country:US
Practice Address - Phone:239-223-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9288589363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025099000Medicaid
FLIC909ZMedicare PIN