Provider Demographics
NPI:1346310067
Name:VANFOSSEN, GREGORY (NP)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:VANFOSSEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3774 BLUE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-8827
Mailing Address - Country:US
Mailing Address - Phone:786-818-9004
Mailing Address - Fax:
Practice Address - Street 1:862 CALLEN LN NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-6995
Practice Address - Country:US
Practice Address - Phone:423-331-5025
Practice Address - Fax:833-450-6211
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21795363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S02784Medicare UPIN