Provider Demographics
NPI:1700601648
Name:DENNIS, VANESSA CAROL
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:CAROL
Last Name:DENNIS
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 1:15717 HEYDEN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1240
Mailing Address - Country:US
Mailing Address - Phone:313-728-2091
Mailing Address - Fax:
Practice Address - Street 1:15717 HEYDEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1240
Practice Address - Country:US
Practice Address - Phone:313-728-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-16
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID520839108827172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver