Healthcare Provider Details

I. General information

NPI: 1730650003
Provider Name (Legal Business Name): VANESSA RENE VASA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 S LEMAY AVE STE 300
FORT COLLINS CO
80524-3955
US

IV. Provider business mailing address

4568 GRAHAM CT
LOVELAND CO
80538-1578
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-7442
  • Fax: 970-493-2990
Mailing address:
  • Phone: 714-397-9132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0186003
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number994462
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: