Healthcare Provider Details

I. General information

NPI: 1487619151
Provider Name (Legal Business Name): RONDA M. VANDERHEIDEN F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 SUMRALL RD
COLUMBIA MS
39429-2654
US

IV. Provider business mailing address

PO BOX 630
COLUMBIA MS
39429-0630
US

V. Phone/Fax

Practice location:
  • Phone: 601-261-2940
  • Fax: 601-261-2942
Mailing address:
  • Phone: 601-261-2940
  • Fax: 601-261-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR717657
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: