Provider Demographics
NPI:1093050353
Name:PINE, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:PINE
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 1:2449 E WATERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-8996
Mailing Address - Country:US
Mailing Address - Phone:260-609-8749
Mailing Address - Fax:
Practice Address - Street 1:11506 NICHOLAS ST
Practice Address - Street 2:STE 110
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4407
Practice Address - Country:US
Practice Address - Phone:877-230-3885
Practice Address - Fax:402-505-9753
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist