Basic Information
Provider Information | |||||||||
NPI: | 1023462694 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAYEN | ||||||||
FirstName: | VANESSA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.N., N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HAYDEN | ||||||||
OtherFirstName: | VANESSA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11247 | ||||||||
Address2: |   | ||||||||
City: | BERKELEY | ||||||||
State: | CA | ||||||||
PostalCode: | 947122247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5109814100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 837 ADDISON ST | ||||||||
Address2: |   | ||||||||
City: | BERKELEY | ||||||||
State: | CA | ||||||||
PostalCode: | 947102047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5109814100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2016 | ||||||||
LastUpdateDate: | 09/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 95038673 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 95004864 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.