Healthcare Provider Details

I. General information

NPI: 1669237384
Provider Name (Legal Business Name): CHRISTINE S VANDERWAL RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 400TH ST
MARNE IA
51552-2102
US

IV. Provider business mailing address

2604 400TH ST
MARNE IA
51552-2102
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-4758
  • Fax:
Mailing address:
  • Phone: 712-732-4758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number088447
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: