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General NPI Number Information
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NPI Number | 1649466384
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Entity Type | Organization
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Legal Business Name | LUCILLE A VANDEVERE, LLC
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Dates
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Enumeration Date | 09/17/2007
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Last Update Date | 03/27/2018
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Provider Practice Location Address
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Address Line | 6989 HANCOCK DR
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-8207
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Country | US
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Telephone | 772-252-4130
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Fax | 772-672-4089
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Provider Business Mailing Address
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Address Line | PO BOX 13300
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City | FORT PIERCE
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State | FL
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Zip | 34979-3300
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Country | US
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Telephone | 772-252-4130
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Fax | 772-672-4089
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | LUCILLE ANN VANDEVERE
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Credential | ARNP
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Telephone | 772-252-4130
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | ARNP3283142
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License Number State | FL
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