Provider Demographics
NPI:1760853378
Name:MIDDLETON, VANNESS
Entity Type:Individual
Prefix:
First Name:VANNESS
Middle Name:
Last Name:MIDDLETON
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 1:4514 FOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2918
Mailing Address - Country:US
Mailing Address - Phone:910-794-3331
Mailing Address - Fax:
Practice Address - Street 1:4514 FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2918
Practice Address - Country:US
Practice Address - Phone:910-794-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management