Healthcare Provider Details

I. General information

NPI: 1477541779
Provider Name (Legal Business Name): MARK J VANVIEGEN ENP/FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 BAL HARBOR BLVD
PUNTA GORDA FL
33950-5205
US

IV. Provider business mailing address

20322 LAGENTE CIRCLE
VENICE FL
34293-5205
US

V. Phone/Fax

Practice location:
  • Phone: 919-426-1756
  • Fax:
Mailing address:
  • Phone: 919-426-1756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number005002286
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14586
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP3029682
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number149084
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN10029872
License Number StateMA
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11846
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: