Provider Demographics
NPI:1104647098
Name:MOFFETT, VANESSA J
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:J
Last Name:MOFFETT
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:PSC 3 BOX 6091
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96266-0061
Mailing Address - Country:US
Mailing Address - Phone:347-779-9824
Mailing Address - Fax:
Practice Address - Street 1:UNIT 2060
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:US
Practice Address - Phone:347-779-9824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9547288207R00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine