Provider Demographics
NPI:1417553942
Name:VANDERBILT, EDWARD ROY (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:ROY
Last Name:VANDERBILT
Suffix:
Gender:
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 IVORHING CT
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-6335
Mailing Address - Country:US
Mailing Address - Phone:336-817-9268
Mailing Address - Fax:
Practice Address - Street 1:1304 ASHLEY SQ
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2919
Practice Address - Country:US
Practice Address - Phone:336-817-9268
Practice Address - Fax:336-396-8041
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013618363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1417553942Medicaid