Provider Demographics
NPI:1386698231
Name:VANDEMARK, WENDY LIANA (MD)
Entity type:Individual
Prefix:DR
First Name:WENDY
Middle Name:LIANA
Last Name:VANDEMARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:LIANA
Other - Last Name:RENATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2109 N PATTERSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2577
Mailing Address - Country:US
Mailing Address - Phone:229-232-4833
Mailing Address - Fax:877-343-0538
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-2577
Practice Address - Country:US
Practice Address - Phone:352-265-7981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN640102084P0800X
WV306852084P0800X
MI43010757742084P0800X
MS291132084P0800X
GA575112084P0800X
FLME1690132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123960700Medicaid