Provider Demographics
NPI:1134711674
Name:VINSON, VANESSA DENISE
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:DENISE
Last Name:VINSON
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 1:4700 CITY AVE APT 12103
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1578
Mailing Address - Country:US
Mailing Address - Phone:240-733-2039
Mailing Address - Fax:
Practice Address - Street 1:4700 CITY AVE APT 12103
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19131-1578
Practice Address - Country:US
Practice Address - Phone:240-733-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA02022019202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology