Healthcare Provider Details

I. General information

NPI: 1871023028
Provider Name (Legal Business Name): TAMARA NICOLE VANDIVER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2427 HWY 255 WEST
BROOKELAND TX
75951
US

IV. Provider business mailing address

10422 DOGWOOD DR
BEAUMONT TX
77705-8726
US

V. Phone/Fax

Practice location:
  • Phone: 409-698-9600
  • Fax: 406-698-2800
Mailing address:
  • Phone: 409-673-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP133604
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: