Provider Demographics
NPI:1730649351
Name:WALL, VANESSA TRA-MI
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:TRA-MI
Last Name:WALL
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 1:11243 S PALISADE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6431 FANNIN ST STE 5.170
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program