MEDICARE: KIRSTYNN VANDERVELDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246Q00000X	Pathology Specialist/Technologist

General Provider Information

NPI Number	:	1003681438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTYNN VANDERVELDE

Provider Business Mailing Address
First Line	:	1810 N LAUREL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-1629
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 N LAUREL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-1629
Country	:	US
Telephone Number	:	661-488-6195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2023
Last Update Date	:	11/15/2023

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Directions to “ KIRSTYNN VANDERVELDE ” Practice Location

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