Provider Demographics
NPI:1538757984
Name:WILSON, VANESSA JANE
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:JANE
Last Name:WILSON
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 1:86 GROVE ST APT B2
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-1803
Mailing Address - Country:US
Mailing Address - Phone:818-317-8377
Mailing Address - Fax:
Practice Address - Street 1:4 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-371-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical