Provider Demographics
NPI:1255777199
Name:DUGAN, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DUGAN
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 1:800 LAKEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5886
Mailing Address - Country:US
Mailing Address - Phone:321-452-2855
Mailing Address - Fax:
Practice Address - Street 1:800 LAKEWOOD CIR
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5886
Practice Address - Country:US
Practice Address - Phone:321-452-2855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906586376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007669000Medicaid