Basic Information
| Provider Information | |||||||||
| NPI: | 1174098933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERARK | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9033 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349959033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722235680 | ||||||||
| FaxNumber: | 7722235622 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SE OSCEOLA ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724192137 | ||||||||
| FaxNumber: | 7724192138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2018 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 9385366 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 104885200 | 05 | FL | MEDICAID | C364K | 01 | FL | FLORIDA BLUE | OTHER |