1265469035 NPI number — VICKI LYNN VANDERKWAAK LISW

Table of content: VICKI LYNN VANDERKWAAK LISW (NPI 1265469035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265469035 NPI number — VICKI LYNN VANDERKWAAK LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERKWAAK
Provider First Name:
VICKI
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265469035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2611 WASHINGTON STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PELLA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-628-9599
Provider Business Mailing Address Fax Number:
641-621-1493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 AURORA AVE
Provider Second Line Business Practice Location Address:
STE 302W
Provider Business Practice Location Address City Name:
URBANDALE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50322-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-331-0303
Provider Business Practice Location Address Fax Number:
515-331-9086
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0136879 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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