Healthcare Provider Details

I. General information

NPI: 1396627824
Provider Name (Legal Business Name): DR. VANESSA ETIENNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. NUM 2, KM. 11.7
BAYAMON PR
00959
US

IV. Provider business mailing address

PO BOX 141174
ARECIBO PR
00614-1174
US

V. Phone/Fax

Practice location:
  • Phone: 787-474-8282
  • Fax:
Mailing address:
  • Phone: 229-395-5645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number17443-I
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: