Basic Information
| Provider Information | |||||||||
| NPI: | 1396368932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDYKE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 FARMHOUSE CT | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290722793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036227652 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7037 SAINT ANDREWS RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292121177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037320963 | ||||||||
| FaxNumber: | 8037321406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2020 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 77820 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.