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General NPI Number Information
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NPI Number | 1619431384
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Entity Type | Individual
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Provider Name | AMY GRACE VANOSDALE PAC
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Gender | Female
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Dates
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Enumeration Date | 01/28/2019
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Last Update Date | 01/28/2019
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Provider Practice Location Address
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Address Line | 820 GOODLETTE RD N
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City | NAPLES
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State | FL
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Zip | 34102-5445
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Country | US
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Telephone | 239-430-3260
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Fax |
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Provider Business Mailing Address
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Address Line | 820 GOODLETTE RD N
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City | NAPLES
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State | FL
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Zip | 34102-5445
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Country | US
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Telephone |
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 9112004
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9112004
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License Number State | FL
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