Provider Demographics
NPI:1922395979
Name:DESOUSA, VANESSA LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:LEE
Last Name:DESOUSA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 OLD REDWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1719
Mailing Address - Country:US
Mailing Address - Phone:707-393-4033
Mailing Address - Fax:
Practice Address - Street 1:3925 OLD REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1719
Practice Address - Country:US
Practice Address - Phone:707-393-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13179208000000X
MA248276208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics