Healthcare Provider Details

I. General information

NPI: 1548183593
Provider Name (Legal Business Name): VANESSA RAQUEL TRAVIESO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 N ESTRELLA PKWY
GOODYEAR AZ
85338-8200
US

IV. Provider business mailing address

387 N ESTRELLA PKWY
GOODYEAR AZ
85338-8200
US

V. Phone/Fax

Practice location:
  • Phone: 623-215-1049
  • Fax:
Mailing address:
  • Phone: 623-215-1049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS027891
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: