Provider Demographics
NPI:1063976942
Name:GARCIA, VANESSA GEORGETTE
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:GEORGETTE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 DAVIE RD APT 215
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-1623
Mailing Address - Country:US
Mailing Address - Phone:305-761-5231
Mailing Address - Fax:
Practice Address - Street 1:180 SW 84TH AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2731
Practice Address - Country:US
Practice Address - Phone:844-665-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8445133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty