Provider Demographics
NPI:1295223592
Name:LARANJO, VANESSA BATO (CEO)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:BATO
Last Name:LARANJO
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7029 UNIONTOWN HWY
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-8214
Mailing Address - Country:US
Mailing Address - Phone:479-242-5883
Mailing Address - Fax:479-242-1925
Practice Address - Street 1:2120 S WALDRON RD STE 3B
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3655
Practice Address - Country:US
Practice Address - Phone:479-242-5883
Practice Address - Fax:479-242-1925
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR5361374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR224878732Medicaid