Provider Demographics
NPI:1528430998
Name:VANDENBURG, AMANDA LYN (APRN-CNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYN
Last Name:VANDENBURG
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OK
Mailing Address - Zip Code:74536-0219
Mailing Address - Country:US
Mailing Address - Phone:918-569-4143
Mailing Address - Fax:918-569-7552
Practice Address - Street 1:415 6TH STREET
Practice Address - Street 2:
Practice Address - City:BOSWELL
Practice Address - State:OK
Practice Address - Zip Code:74727-0000
Practice Address - Country:US
Practice Address - Phone:580-566-2530
Practice Address - Fax:580-566-2533
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK73707363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner