Basic Information
| Provider Information | |||||||||
| NPI: | 1417073115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VARGAS | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 NE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413822811 | ||||||||
| FaxNumber: | 5413223501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 NE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413822811 | ||||||||
| FaxNumber: | 5413223501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 912650 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 500614159 | 05 | OR | MEDICAID |