Provider Demographics
NPI:1740903665
Name:WYDRA, VANESSA (RN)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:WYDRA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-3514
Mailing Address - Country:US
Mailing Address - Phone:201-755-3551
Mailing Address - Fax:
Practice Address - Street 1:4977 NORTHCUTT PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3839
Practice Address - Country:US
Practice Address - Phone:937-387-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRB.513623163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse