=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508321662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER LYNN VANDERWAGEN AGACNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2019
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1223 MERCY DR
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-1879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-672-3500
-----------------------------------------------------
Fax | 231-672-6199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776982
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-494-5797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 4704298974
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------