Provider Demographics
NPI:1164587234
Name:WERLLA, VANESSA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:LYNN
Last Name:WERLLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 E. 43RD ST.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105
Mailing Address - Country:US
Mailing Address - Phone:918-712-7488
Mailing Address - Fax:918-712-7488
Practice Address - Street 1:1707 E. 43RD ST.
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105
Practice Address - Country:US
Practice Address - Phone:918-712-7488
Practice Address - Fax:918-712-7404
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK133742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1113374Medicaid
OK8775679230Medicare UPIN