Provider Demographics
NPI:1073501979
Name:VANDENBURG, KATHLEEN D (ARNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:VANDENBURG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1220
Mailing Address - Street 2:199 ROUTE 101
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MEETING PLACE PLAZA 199 ROUTE 101
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-1734
Practice Address - Country:US
Practice Address - Phone:603-249-3000
Practice Address - Fax:603-249-3000
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH030002-23-03363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30340851Medicaid
NH0140741OtherUHC
NH437820OtherCIGNA
NHS45443OtherANTHEM UPIN REFERRAL #
NH030001OtherTUFTS
NHS45443OtherHPHC
NHNP2391Medicare ID - Type UnspecifiedMEDICARE
NH0140741OtherUHC