Provider Demographics
NPI:1184748105
Name:VILLEGAS, VANNESA JOY TARECTECAN
Entity type:Individual
Prefix:
First Name:VANNESA JOY
Middle Name:TARECTECAN
Last Name:VILLEGAS
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 1:5980 W 71ST ST STE 201
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1785
Mailing Address - Country:US
Mailing Address - Phone:317-388-0800
Mailing Address - Fax:317-388-0805
Practice Address - Street 1:410 W GULF ATLANTIC HWY
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-7301
Practice Address - Country:US
Practice Address - Phone:352-259-2159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FLPT22906225100000X
IN05008245A171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171W00000XOther Service ProvidersContractor