Provider Demographics
NPI:1104435346
Name:VANDERGRIFT, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:VANDERGRIFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21106 CREEK SIDE DR SW
Mailing Address - Street 2:
Mailing Address - City:WESTERNPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21562-2001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21106 CREEK SIDE DR SW
Practice Address - Street 2:
Practice Address - City:WESTERNPORT
Practice Address - State:MD
Practice Address - Zip Code:21562-2001
Practice Address - Country:US
Practice Address - Phone:301-723-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant