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General NPI Number Information
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NPI Number | 1417553942
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Entity Type | Individual
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Provider Name | EDWARD ROY VANDERBILT MSN, APRN, FNP-C
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Gender | Male
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Dates
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Enumeration Date | 12/09/2020
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Last Update Date | 03/11/2025
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Provider Practice Location Address
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Address Line | 1304 ASHLEY SQ
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City | WINSTON SALEM
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State | NC
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Zip | 27103-2919
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Country | US
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Telephone | 336-817-9268
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Fax | 336-396-8041
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Provider Business Mailing Address
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Address Line | 120 IVORHING CT
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City | KERNERSVILLE
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State | NC
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Zip | 27284-6335
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Country | US
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Telephone | 336-817-9268
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 5013618
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 5013618
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License Number State | NC
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