Kathleen Vanderreyden, NP

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

71009667A Issued in IN

Practice address

3030 Lake Ave Ste 24
Fort Wayne, IN 46805-5428

Phone

(260) 201-3119

Fax

(260) 233-7416

NPI assigned

Jan 17, 2020

Last updated

Jul 6, 2026By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2019

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Legacy Treatment Center LLCGroup PAC ID 9133615040, 2 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/26403/brand/1/csg/1/fhir/r4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Legacy Treatment Center LLC

  • Addiction Medicine (Family Medicine) Physician
  • Fort Wayne, IN
  • NPI 1336940717
  Medicare reassignment Care Compare group NPD
• Cleanslate Medical Group of Indiana LLC

  • Addiction Medicine (Internal Medicine) Physician
  • Alexandria, IN
  • NPI 1023464294
  Medicare reassignment NPD
• Fort Wayne Primary Care LLC

  • Internal Medicine Physician
  • Fort Wayne, IN
  • NPI 1528707619
  Medicare reassignment NPD
• Chicagoland Infectious Disease PC

  • Infectious Disease Physician
  • South Holland, IL
  • NPI 1780002352

  IN

  Medicare reassignment NPD
• Hoosier Sports & Chiropractic LLC

  • Chiropractor
  • Fort Wayne, IN
  • NPI 1801114533
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1579219200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1783296000000",
    "number": "1225668312",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3030 LAKE AVE STE 24",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468055428",
            "telephone_number": "260-201-3119",
            "fax_number": "260-233-7416"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3030 LAKE AVE STE 24",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468055428",
            "telephone_number": "260-201-3119",
            "fax_number": "260-233-7416"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VANDERREYDEN",
        "first_name": "KATHLEEN",
        "name_prefix": "Mrs.",
        "credential": "NP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-01-17",
        "last_updated": "2026-07-06",
        "certification_date": "2026-07-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "IN",
            "license": "71009667A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Heather L Vandentop
• Cynthia L. Vanderbosch, M.D.
• Trever Vanderhorst, MD
• Craig William Vandermaden, PTA
• Emily Nicole Vandermaden, DPT
• Robin Gene Vandeventer
• Natalie Vandezande
• Vance V Vandrake, MD
• Michelle L Vanek, PTA
• Erika J Vanengen, PT

• Nurse Practitioner in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• Nurse Practitioner in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.