Healthcare Provider Details

I. General information

NPI: 1790723260
Provider Name (Legal Business Name): DELORES A. VANDERGRIFT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 FAIRLAWN DR
CARTHAGE MO
64836-3517
US

IV. Provider business mailing address

2425 FAIRLAWN DR
CARTHAGE MO
64836-3517
US

V. Phone/Fax

Practice location:
  • Phone: 417-237-0604
  • Fax: 417-237-0613
Mailing address:
  • Phone: 417-237-0604
  • Fax: 417-237-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number079678
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: