Provider Demographics
NPI:1235539016
Name:TREVATHAN, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:TREVATHAN
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 1:540 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27253-2158
Mailing Address - Country:US
Mailing Address - Phone:336-227-0730
Mailing Address - Fax:336-227-0732
Practice Address - Street 1:124 W CRESCENT SQUARE DR
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:NC
Practice Address - Zip Code:27253-4014
Practice Address - Country:US
Practice Address - Phone:336-227-0730
Practice Address - Fax:336-227-0732
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704282Medicaid