Provider Demographics
NPI:1205853959
Name:BRUTON, VANESSA WANDA
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:WANDA
Last Name:BRUTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-6110
Mailing Address - Country:US
Mailing Address - Phone:954-410-9794
Mailing Address - Fax:
Practice Address - Street 1:1425 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-6110
Practice Address - Country:US
Practice Address - Phone:954-410-9794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor