Provider Demographics
NPI:1295184059
Name:MICKA, VANESSA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MICKA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:109 W 27TH ST STE 5S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 W 27TH ST STE 5S
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6208
Practice Address - Country:US
Practice Address - Phone:917-634-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-11
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY674658163W00000X
NY402299363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse