Healthcare Provider Details

I. General information

NPI: 1982426177
Provider Name (Legal Business Name): RENAE M VESSOV RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD RM N-425
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

100 BREWSTER BLVD RM N-425
CAMP LEJEUNE NC
28547-2575
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4582
  • Fax: 910-450-3211
Mailing address:
  • Phone: 910-450-4582
  • Fax: 910-450-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number616010
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number260717
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: