Healthcare Provider Details

I. General information

NPI: 1275415887
Provider Name (Legal Business Name): MRS. VANESSA RENAE MADDOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 3RD ST STE 2
RIVERSIDE CA
92507-3454
US

IV. Provider business mailing address

1410 3RD ST STE 2
RIVERSIDE CA
92507-3454
US

V. Phone/Fax

Practice location:
  • Phone: 951-956-8532
  • Fax:
Mailing address:
  • Phone: 951-956-8532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: