Healthcare Provider Details

I. General information

NPI: 1831642594
Provider Name (Legal Business Name): ELIZABETH VANWAGENEN RN 320463
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 BROWNS VALLEY RD
WATSONVILLE CA
95076-0325
US

IV. Provider business mailing address

143 BROWNS VALLEY RD
WATSONVILLE CA
95076-0325
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-3285
  • Fax: 831-728-5900
Mailing address:
  • Phone: 831-728-3285
  • Fax: 831-728-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number31403
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number320463
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: