Provider Demographics
NPI:1639500481
Name:MADDEN-GILYARD, VANESSA MARIE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:MARIE
Last Name:MADDEN-GILYARD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:MARIE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:10421 KEMPSFORD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2718
Mailing Address - Country:US
Mailing Address - Phone:980-433-0517
Mailing Address - Fax:
Practice Address - Street 1:113 BALLAD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-1224
Practice Address - Country:US
Practice Address - Phone:585-267-0588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY667652-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY667652-1OtherLICENSE NUMBER