Provider Demographics
NPI:1982587259
Name:ROMAN, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 CULVER BLVD # 1182
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7704
Mailing Address - Country:US
Mailing Address - Phone:323-403-8058
Mailing Address - Fax:
Practice Address - Street 1:322 CULVER BLVD # 1182
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-7704
Practice Address - Country:US
Practice Address - Phone:323-403-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-25
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036236363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health