Basic Information
| Provider Information | |||||||||
| NPI: | 1740557610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERMARK | ||||||||
| FirstName: | PAMELA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W RAMPART ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173980121 | ||||||||
| FaxNumber: | 3173980538 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 INTELLIPLEX DR STE 260 | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173980121 | ||||||||
| FaxNumber: | 3173980538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2011 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28154814A | IN | N | Nursing Service Providers | Registered Nurse | 363LG0600X | 71003764A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 201042790 | 05 | IN | MEDICAID |