1780978973 NPI number — MS. VANESSA ELIZABETH SODERSTROM MSED

Table of content: MS. VANESSA ELIZABETH SODERSTROM MSED (NPI 1780978973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780978973 NPI number — MS. VANESSA ELIZABETH SODERSTROM MSED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SODERSTROM
Provider First Name:
VANESSA
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780978973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
514 83RD ST
Provider Second Line Business Mailing Address:
APT 2R
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11209-4522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-986-5535
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
514 83RD ST
Provider Second Line Business Practice Location Address:
APT 2R
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11209-4522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-986-5535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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