Healthcare Provider Details

I. General information

NPI: 1184748105
Provider Name (Legal Business Name): VANNESA JOY TARECTECAN VILLEGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W GULF ATLANTIC HWY
WILDWOOD FL
34785-7301
US

IV. Provider business mailing address

5980 W 71ST ST STE 201
INDIANAPOLIS IN
46278-1785
US

V. Phone/Fax

Practice location:
  • Phone: 352-259-2159
  • Fax:
Mailing address:
  • Phone: 317-388-0800
  • Fax: 317-388-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number05008245A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22906
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: