Provider Demographics
NPI:1023643715
Name:MCBRIDE, VANESSA LOUISE (NP-C)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:LOUISE
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:LOUISE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:214 BARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-9239
Mailing Address - Country:US
Mailing Address - Phone:601-832-0974
Mailing Address - Fax:
Practice Address - Street 1:5160 GALAXIE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4308
Practice Address - Country:US
Practice Address - Phone:601-713-0890
Practice Address - Fax:601-366-3415
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03138202Medicaid
1G0833OtherPTAN
MS903727OtherSTATE LICENSE NUMBER