Provider Demographics
NPI:1649551532
Name:AVILA, VANESSA M
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:M
Last Name:AVILA
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 1:7715 NW 48TH ST
Mailing Address - Street 2:SUITE #350 &360
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5455
Mailing Address - Country:US
Mailing Address - Phone:305-846-9087
Mailing Address - Fax:305-846-9711
Practice Address - Street 1:7715 NW 48TH ST
Practice Address - Street 2:SUITE #350 &360
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-5455
Practice Address - Country:US
Practice Address - Phone:305-846-9087
Practice Address - Fax:305-846-9711
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA140873907650390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program