Provider Demographics
NPI:1750653556
Name:WALDREP, VANESSA (CPNP)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:
Last Name:WALDREP
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11908 DARNESTOWN RD STE H
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11908 DARNESTOWN RD STE H
Practice Address - Street 2:
Practice Address - City:NORTH POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20878-2295
Practice Address - Country:US
Practice Address - Phone:301-990-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000987363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics