Healthcare Provider Details

I. General information

NPI: 1992809578
Provider Name (Legal Business Name): MARYANN VANDERMARK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4960 SW 72ND AVE SUITE 400
MIAMI FL
33155-5544
US

IV. Provider business mailing address

1110 N RIVERSIDE DRIVE APT 14
POMPANO BEACH FL
33062
US

V. Phone/Fax

Practice location:
  • Phone: 561-688-4537
  • Fax:
Mailing address:
  • Phone: 732-604-6541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberARNP9295000
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: