Provider Demographics
NPI:1376914192
Name:VAN DAM, ANNETTE (APRN)
Entity type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:
Last Name:VAN DAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:DAVID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:796 NINEVAH RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-7960
Mailing Address - Country:US
Mailing Address - Phone:606-215-0525
Mailing Address - Fax:
Practice Address - Street 1:3151 BEAUMONT CENTRE CIRCLE
Practice Address - Street 2:SUITE 100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1849
Practice Address - Country:US
Practice Address - Phone:859-410-6101
Practice Address - Fax:859-410-6102
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009783202D00000X, 208D00000X, 363L00000X, 363LF0000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily