Provider Demographics
NPI:1649466384
Name:LUCILLE A VANDEVERE, LLC
Entity type:Organization
Organization Name:LUCILLE A VANDEVERE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VANDEVERE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:772-252-4130
Mailing Address - Street 1:PO BOX 13300
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34979-3300
Mailing Address - Country:US
Mailing Address - Phone:772-252-4130
Mailing Address - Fax:772-672-4089
Practice Address - Street 1:6989 HANCOCK DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-8207
Practice Address - Country:US
Practice Address - Phone:772-252-4130
Practice Address - Fax:772-672-4089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3283142261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8765YMedicare UPIN