=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932721982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA REDEAUX
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2020
-----------------------------------------------------
Last Update Date | 05/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 N AUSTIN AVE
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-677-2895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17414 ZOLA LN
-----------------------------------------------------
City | ROUND ROCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78664-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-413-3088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT4106
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------