Provider Demographics
NPI:1174098933
Name:VANDERARK, TAYLOR LEIGH (ARNP)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LEIGH
Last Name:VANDERARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NEBRASKA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4832
Mailing Address - Country:US
Mailing Address - Phone:772-465-8100
Mailing Address - Fax:772-465-8689
Practice Address - Street 1:2100 NEBRASKA AVE STE 201
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4832
Practice Address - Country:US
Practice Address - Phone:772-465-8100
Practice Address - Fax:772-465-8689
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9385366363LA2100X
FLAPRN9385366363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC364KOtherFLORIDA BLUE
FL104885200Medicaid