=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558184812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA PEREZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2403 PROFESSIONAL DR
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-544-3295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 963 MADRONE RD # ATPB6
-----------------------------------------------------
City | GLEN ELLEN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95442-9686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-890-2205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246Z00000X
-----------------------------------------------------
Taxonomy Name | Other Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------