Healthcare Provider Details

I. General information

NPI: 1922089804
Provider Name (Legal Business Name): JOHN DANIEL VANDEVELDE PNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 VISCAYA PKWY STE 101
CAPE CORAL FL
33990-3252
US

IV. Provider business mailing address

12730 NEW BRITTANY BLVD STE 602
FORT MYERS FL
33907-4690
US

V. Phone/Fax

Practice location:
  • Phone: 239-573-7337
  • Fax: 239-574-5883
Mailing address:
  • Phone: 239-275-5522
  • Fax: 239-275-4464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP 9455776
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: