Provider Demographics
NPI:1720668262
Name:VANDERPOOL, CAREN LEE (AGNP)
Entity Type:Individual
Prefix:
First Name:CAREN
Middle Name:LEE
Last Name:VANDERPOOL
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E PONDEROSA PKWY APT 260
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3358
Mailing Address - Country:US
Mailing Address - Phone:760-636-3310
Mailing Address - Fax:
Practice Address - Street 1:1521 N PINE CLIFF DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3269
Practice Address - Country:US
Practice Address - Phone:928-440-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ245358363LA2200X
OR202114853NP-PP363LA2200X
CA95018551363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health