Provider Demographics
NPI:1164243002
Name:VANDIVER, CAROL LYNN
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:LYNN
Last Name:VANDIVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:LYNN
Other - Last Name:VANDIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 S JANE LN
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5060
Mailing Address - Country:US
Mailing Address - Phone:580-478-5650
Mailing Address - Fax:
Practice Address - Street 1:1625 W GARRIOTT RD STE F
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5653
Practice Address - Country:US
Practice Address - Phone:580-242-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator