Healthcare Provider Details

I. General information

NPI: 1578484572
Provider Name (Legal Business Name): SYDNEY VANDAELE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HOSPITAL DR
CRESTVIEW FL
32539-7355
US

IV. Provider business mailing address

206 CITADEL LN
CRESTVIEW FL
32539-4359
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-3146
  • Fax:
Mailing address:
  • Phone: 309-883-4042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF07261006
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: