Basic Information
| Provider Information | |||||||||
| NPI: | 1104906577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIRANI | ||||||||
| FirstName: | VANESSA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 WILLOW FALLS TRL | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320814401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042363799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 540 KINGSLEY AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042642156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT31802 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 889169900 | 05 | FL | MEDICAID |