Provider Demographics
NPI:1104655893
Name:VANDYNE PMHNP, KANDISE J
Entity type:Individual
Prefix:
First Name:KANDISE
Middle Name:J
Last Name:VANDYNE PMHNP
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 1:1105 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-1189
Mailing Address - Country:US
Mailing Address - Phone:970-623-3542
Mailing Address - Fax:
Practice Address - Street 1:1105 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1189
Practice Address - Country:US
Practice Address - Phone:575-746-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77982363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health