Healthcare Provider Details

I. General information

NPI: 1023630555
Provider Name (Legal Business Name): VANESSA VICTORIA GREGORIUS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VANESSA VICTORIA CISNEROS

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 09/08/2021
Certification Date: 08/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12728 19TH AVE SE # 102
EVERETT WA
98208-6526
US

IV. Provider business mailing address

12728 19TH AVE SE # 102
EVERETT WA
98208-6526
US

V. Phone/Fax

Practice location:
  • Phone: 425-353-5544
  • Fax:
Mailing address:
  • Phone: 425-353-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD61072477
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: