Provider Demographics
NPI:1568285534
Name:UDOM, VANESSA IFUNANYA (RN)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:IFUNANYA
Last Name:UDOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:IFY
Other - Middle Name:
Other - Last Name:UDOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:427 BLUE RIDGE DR APT G104
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2772
Mailing Address - Country:US
Mailing Address - Phone:706-559-8641
Mailing Address - Fax:
Practice Address - Street 1:427 BLUE RIDGE DR APT G104
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-2772
Practice Address - Country:US
Practice Address - Phone:706-559-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209604163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse