Provider Demographics
NPI:1790938082
Name:TRIUMPH, VANESSA RENE (RN)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:RENE
Last Name:TRIUMPH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 JERUSALEM AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4980
Mailing Address - Country:US
Mailing Address - Phone:516-326-2020
Mailing Address - Fax:
Practice Address - Street 1:20 JERUSALEM AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4980
Practice Address - Country:US
Practice Address - Phone:516-326-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY503524163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6004868816231103611Medicaid
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