Provider Demographics
NPI:1467118794
Name:DAVIES, VANESSA (AA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DAVIES
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:KLEISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8700
Mailing Address - Fax:414-259-1522
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8700
Practice Address - Fax:414-259-1522
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COANT.0000167367H00000X
WI537367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467118794Medicaid