1649934282 NPI number — MRS. VANESSA LAQUETTA FREEMAN PA-C

Table of content: MRS. VANESSA LAQUETTA FREEMAN PA-C (NPI 1649934282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649934282 NPI number — MRS. VANESSA LAQUETTA FREEMAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEMAN
Provider First Name:
VANESSA
Provider Middle Name:
LAQUETTA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1649934282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5257 NW TORINO LAKES CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34986-3238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-769-4234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 DOMINIQUE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-5482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-584-5046
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2021

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: 2083X0100X , with the licence number:  1166762 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com