Provider Demographics
NPI:1548752652
Name:VEGA, ANNA BROOKE
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:BROOKE
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:VEGA
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MCD, CF-SLP
Mailing Address - Street 1:1001 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4103
Mailing Address - Country:US
Mailing Address - Phone:334-730-8033
Mailing Address - Fax:
Practice Address - Street 1:5176 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-2802
Practice Address - Country:US
Practice Address - Phone:334-730-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002704390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program