Provider Demographics
NPI:1194572396
Name:BALOUS, VANESSA IVETTE (PMHNP)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:IVETTE
Last Name:BALOUS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 AMBOY DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-5202
Mailing Address - Country:US
Mailing Address - Phone:386-561-3873
Mailing Address - Fax:
Practice Address - Street 1:2401 E GRAVES AVE STE 19
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8582
Practice Address - Country:US
Practice Address - Phone:386-561-3873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-04
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11036305363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health