=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831859834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ANN VANDENBERG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2021
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 WESTLAKES DR STE 3152
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19312-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-346-6050
-----------------------------------------------------
Fax | 212-220-3562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 142 WILDFLOWER CT
-----------------------------------------------------
City | ELVERSON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19520-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-888-5867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP025073
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------