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General NPI Number Information
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NPI Number | 1104655893
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Entity Type | Individual
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Provider Name | KANDISE J VANDYNE PMHNP
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Gender | Female
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Dates
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Enumeration Date | 07/30/2024
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 1105 MEMORIAL DR
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City | ARTESIA
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State | NM
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Zip | 88210-1189
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Country | US
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Telephone | 575-746-9848
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Fax |
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Provider Business Mailing Address
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Address Line | 1105 MEMORIAL DR
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City | ARTESIA
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State | NM
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Zip | 88210-1189
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Country | US
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Telephone | 970-623-3542
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 77982
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License Number State | NM
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