Provider Demographics
NPI:1013420660
Name:BALLARD, VANESA NICOLE
Entity Type:Individual
Prefix:
First Name:VANESA
Middle Name:NICOLE
Last Name:BALLARD
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 1:1219 K ST NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29716 STATE HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:OK
Practice Address - Zip Code:73437-7343
Practice Address - Country:US
Practice Address - Phone:580-222-6261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker