=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376914192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE VAN DAM APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2015
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 E. STATE ST. OFFICE 233 COLUMBUS, OH 43215 OFFIXE 233
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-731-8994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 796 NINEVAH RD
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40601-7960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-731-8994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 3009783
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 3009783
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 3009783
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 202D00000X
-----------------------------------------------------
Taxonomy Name | Integrative Medicine Physician
-----------------------------------------------------
License Number | 3009783
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 3009783
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------