Provider Demographics
NPI:1346750437
Name:AMBERG, LAKEN JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:LAKEN
Middle Name:JEAN
Last Name:AMBERG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6843 E 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1831
Mailing Address - Country:US
Mailing Address - Phone:907-631-9423
Mailing Address - Fax:
Practice Address - Street 1:7801 SCHOON ST STE B
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-3039
Practice Address - Country:US
Practice Address - Phone:907-344-0376
Practice Address - Fax:907-344-0708
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116666225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK116666OtherPROFESSIONAL LICENSE