Provider Demographics
NPI:1568597037
Name:SUFFOLETTA, VANESSA G (APRN)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:G
Last Name:SUFFOLETTA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950245
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0245
Mailing Address - Country:US
Mailing Address - Phone:502-272-5100
Mailing Address - Fax:502-272-5114
Practice Address - Street 1:12615 TAYLORSVILLE RD
Practice Address - Street 2:STE. B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4452
Practice Address - Country:US
Practice Address - Phone:502-261-1565
Practice Address - Fax:502-261-1569
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3051P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000697994OtherANTHEM-NICC
KY122252OtherSIHO-NICC
KY78006236Medicaid
KY61-1276316OtherTIN-NICC
KYP400041680Medicare PIN
KY122252OtherSIHO-NICC
KY61-1276316OtherTIN-NICC