Basic Information
| Provider Information | |||||||||
| NPI: | 1306135751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VARGAS | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | ILIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2859 GOLDEN POND BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320737665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562512035 | ||||||||
| FaxNumber: | 9567914422 | ||||||||
| Practice Location | |||||||||
| Address1: | 12276 SAN JOSE BLVE | ||||||||
| Address2: | SUITE 508 | ||||||||
| City: | JACKSONVILEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322228618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | 9044047743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 35922 | TX | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 2355S0801X | SZ7526 | FL | N | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
| ID | Type | State | Issuer | Description | SZ7526 | 01 | FL | SPEECH LICENCE | OTHER | 35922 | 01 | TX | STATE LICENSE | OTHER |