Healthcare Provider Details

I. General information

NPI: 1750679486
Provider Name (Legal Business Name): VANESSA A NITIBHON M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VANESSA A GARDNER

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE SUITE 160
VANCOUVER WA
98664
US

IV. Provider business mailing address

505 NE 87TH AVE SUITE 160
VANCOUVER WA
98664
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-6060
  • Fax: 360-514-6074
Mailing address:
  • Phone: 360-514-6060
  • Fax: 360-514-6074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: