Basic Information
| Provider Information | |||||||||
| NPI: | 1417401118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDER KELEN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | DEBRA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LM, CPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARKER | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LM,CPM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6931 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346532502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274853363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 215 LITHIA PINECREST RD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136858404 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | MW335 | FL | Y | Other Service Providers | Midwife |
No ID Information.