Healthcare Provider Details

I. General information

NPI: 1073762225
Provider Name (Legal Business Name): DIANE VIRGINIA VANDE POL CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 LAWRENCE EXPY
SANTA CLARA CA
95051-5173
US

IV. Provider business mailing address

700 LAWRENCE EXPY
SANTA CLARA CA
95051-5173
US

V. Phone/Fax

Practice location:
  • Phone: 408-851-7172
  • Fax:
Mailing address:
  • Phone: 408-851-7172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number307602
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: