=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922651322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER LYNN VANDENBOS APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2019
-----------------------------------------------------
Last Update Date | 01/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 284 ROOST AVE
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49424-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-377-4655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5327 EAGLE PASS DR
-----------------------------------------------------
City | HUDSONVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49426-9529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-376-4457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | APN.0994775-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704373321
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------