Provider Demographics
NPI:1780175380
Name:MABAZZA, MA VANESSA S (APRN,NP-C,AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:MA VANESSA
Middle Name:S
Last Name:MABAZZA
Suffix:
Gender:F
Credentials:APRN,NP-C,AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 HAUSER ROSS DR STE 350
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3181
Mailing Address - Country:US
Mailing Address - Phone:815-758-7700
Mailing Address - Fax:815-756-6103
Practice Address - Street 1:2550 HAUSER ROSS DRIVE
Practice Address - Street 2:SUITE 350
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-758-7700
Practice Address - Fax:815-756-6103
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209017671363L00000X, 363L00000X
IL041345967163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse