Provider Demographics
NPI:1497447528
Name:FERKETICH, VANESSA (OWNER)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:FERKETICH
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 LONG LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-1617
Mailing Address - Country:US
Mailing Address - Phone:904-494-8560
Mailing Address - Fax:
Practice Address - Street 1:4 LONG LAKE WAY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-1617
Practice Address - Country:US
Practice Address - Phone:904-494-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography