Provider Demographics
NPI:1952094971
Name:VANDENBERG, TAMMIE RAE
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:RAE
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6873 SIDEROAD 15
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N0G2K0
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3851 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5515
Practice Address - Country:US
Practice Address - Phone:772-882-4919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11025960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily