Provider Demographics
NPI:1063648210
Name:VANNESS, BERNADETTE ANN (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:ANN
Last Name:VANNESS
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 TRUEMPER ST
Mailing Address - Street 2:
Mailing Address - City:LACKLAND A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5511
Mailing Address - Country:US
Mailing Address - Phone:210-671-2651
Mailing Address - Fax:
Practice Address - Street 1:1618 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-5511
Practice Address - Country:US
Practice Address - Phone:210-671-2651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians