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General NPI Number Information
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NPI Number | 1679285779
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Entity Type | Individual
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Provider Name | MICAH NICOLE VANDE VEGTE NP-C
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Gender | Female
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Dates
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Enumeration Date | 12/20/2022
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Last Update Date | 12/20/2022
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Provider Practice Location Address
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Address Line | 220 E RIVER PKWY UNIT 428
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City | CHAMPLIN
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State | MN
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Zip | 55316-1426
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Country | US
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Telephone | 712-395-8621
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Fax |
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Provider Business Mailing Address
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Address Line | 220 E RIVER PKWY UNIT 428
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City | CHAMPLIN
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State | MN
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Zip | 55316-1426
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Country | US
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Telephone | 712-395-8621
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | F10221396
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License Number State | IA
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