Healthcare Provider Details

I. General information

NPI: 1083916712
Provider Name (Legal Business Name): VANESSA VATH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BROADWAY
SOMERVILLE MA
02145-2935
US

IV. Provider business mailing address

300 BROADWAY
SOMERVILLE MA
02145-2935
US

V. Phone/Fax

Practice location:
  • Phone: 617-284-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN269234
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: