Provider Demographics
NPI:1609017391
Name:ROMAN, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 BALLARD COVE RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-2251
Mailing Address - Country:US
Mailing Address - Phone:407-994-6637
Mailing Address - Fax:
Practice Address - Street 1:2358 BALLARD COVE RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-2251
Practice Address - Country:US
Practice Address - Phone:407-994-6637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 3747P1801X, 251E00000X
FLSA10745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000170001Medicaid
FL000867501Medicaid
FL000867500Medicaid
FL000170000Medicaid
FL000867502Medicaid