Basic Information
| Provider Information | |||||||||
| NPI: | 1932685898 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAYMOND | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | G. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5086 STARBLAZE DR | ||||||||
| Address2: | |||||||||
| City: | GREENACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334635934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617296163 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2815 S SEACREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334357969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617377733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2018 | ||||||||
| LastUpdateDate: | 07/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 9392417 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 9392417 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 9392417 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.