Provider Demographics
NPI:1679285779
Name:VANDE VEGTE, MICAH NICOLE (NP-C)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:NICOLE
Last Name:VANDE VEGTE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E RIVER PKWY UNIT 428
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-1426
Mailing Address - Country:US
Mailing Address - Phone:712-395-8621
Mailing Address - Fax:
Practice Address - Street 1:220 E RIVER PKWY UNIT 428
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-1426
Practice Address - Country:US
Practice Address - Phone:712-395-8621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAF10221396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily