Provider Demographics
NPI:1215995121
Name:FRIDGE, VANESSA RUSSELL (OT)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:RUSSELL
Last Name:FRIDGE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86144
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36689-6144
Mailing Address - Country:US
Mailing Address - Phone:251-476-5050
Mailing Address - Fax:251-450-2770
Practice Address - Street 1:6144 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3143
Practice Address - Country:US
Practice Address - Phone:251-476-5050
Practice Address - Fax:251-450-2770
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1958225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
03014Medicare UPIN