Provider Demographics
NPI:1316420169
Name:LANDRUM, VANESSA JEAN (LVN)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:JEAN
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7419 102ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-8446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:806-687-3358
Practice Address - Street 1:7419 102ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-8446
Practice Address - Country:US
Practice Address - Phone:806-687-3124
Practice Address - Fax:806-687-3358
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX151403164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid