Provider Demographics
NPI:1275903023
Name:REYES, VANESSA K
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:K
Last Name:REYES
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 1:999 MONTE CARLO DR N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-5529
Mailing Address - Country:US
Mailing Address - Phone:701-318-6917
Mailing Address - Fax:
Practice Address - Street 1:999 MONTE CARLO DR N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-5529
Practice Address - Country:US
Practice Address - Phone:701-318-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1456157171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1456157Medicare PIN