Provider Demographics
NPI:1487619151
Name:VANDERHEIDEN, RONDA M (FNP)
Entity type:Individual
Prefix:MS
First Name:RONDA
Middle Name:M
Last Name:VANDERHEIDEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-0630
Mailing Address - Country:US
Mailing Address - Phone:601-261-2940
Mailing Address - Fax:601-261-2942
Practice Address - Street 1:1560 SUMRALL RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2654
Practice Address - Country:US
Practice Address - Phone:601-261-2940
Practice Address - Fax:601-261-2942
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR717657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04155392Medicaid
MS2555680OtherUNITED HEALTH CARE
MS4414516P01OtherCIGNA
MS7264860OtherAETNA
MS04155392Medicaid
MS7264860OtherAETNA