Basic Information
| Provider Information | |||||||||
| NPI: | 1659840767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN DAM | ||||||||
| FirstName: | LINDSAY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6020 E ARBOR AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852066102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851700 | ||||||||
| FaxNumber: | 4803963659 | ||||||||
| Practice Location | |||||||||
| Address1: | 6020 E ARBOR AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852066102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851700 | ||||||||
| FaxNumber: | 4803963659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2018 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN166378 | AZ | N | Nursing Service Providers | Registered Nurse | 363LA2100X | 220794 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | RN166378 | 01 | AZ | NURSING LICENSE | OTHER | 220794 | 01 | AZ | NURSE PRACTITIONER | OTHER |