Provider Demographics
NPI:1528697174
Name:VANDIVER, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:VANDIVER
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 1:5488 STONE LEDGE CIR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-2554
Mailing Address - Country:US
Mailing Address - Phone:913-620-6698
Mailing Address - Fax:
Practice Address - Street 1:3870 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-8689
Practice Address - Country:US
Practice Address - Phone:573-302-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020000395363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily