Healthcare Provider Details

I. General information

NPI: 1558736850
Provider Name (Legal Business Name): VANESSA PUTNAM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR FAMILY HEALTH CLINIC
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR FAMILY HEALTH CLINIC
WRIGHT PATTERSON AFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9260
  • Fax:
Mailing address:
  • Phone: 937-257-9260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.17621-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: