Provider Demographics
NPI:1831770684
Name:VANDERWALL, VICTORIA LAUREN (RN)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LAUREN
Last Name:VANDERWALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:164 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-6080
Mailing Address - Country:US
Mailing Address - Phone:423-290-8227
Mailing Address - Fax:
Practice Address - Street 1:2525 DESALES AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1161
Practice Address - Country:US
Practice Address - Phone:423-290-8227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN214818163W00000X
TN30423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse