Provider Demographics
NPI:1023630555
Name:GREGORIUS, VANESSA VICTORIA (OD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:VICTORIA
Last Name:GREGORIUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:VICTORIA
Other - Last Name:CISNEROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12728 19TH AVE SE # 102
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6526
Mailing Address - Country:US
Mailing Address - Phone:425-353-5544
Mailing Address - Fax:
Practice Address - Street 1:12728 19TH AVE SE # 102
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6526
Practice Address - Country:US
Practice Address - Phone:425-353-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61072477152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist