Provider Demographics
NPI:1457015307
Name:ILIAS, VANESSA (AGACNP-BC, APRN)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:ILIAS
Suffix:
Gender:F
Credentials:AGACNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR ST STE 425
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5523
Mailing Address - Country:US
Mailing Address - Phone:860-548-7336
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST STE 425
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5523
Practice Address - Country:US
Practice Address - Phone:860-548-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11280363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care