Provider Demographics
NPI:1093019994
Name:VANDERBERG, ANGELA M (APN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:VANDERBERG
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 W 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8745
Mailing Address - Country:US
Mailing Address - Phone:219-614-9528
Mailing Address - Fax:
Practice Address - Street 1:215 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1917
Practice Address - Country:US
Practice Address - Phone:574-325-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003513363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ2007010OtherMEDICARE PTAN
ININ2007010Medicare UPIN