Provider Demographics
NPI:1063814622
Name:TAJALLE, VANESSA ANN (MS)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:ANN
Last Name:TAJALLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 CHAPEL HILL DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1925
Mailing Address - Country:US
Mailing Address - Phone:631-434-8852
Mailing Address - Fax:
Practice Address - Street 1:61 CHAPEL HILL DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1925
Practice Address - Country:US
Practice Address - Phone:631-434-8852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY49581011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist