Provider Demographics
NPI:1407203276
Name:MASSIE, ANNELYSSA LEE (LMT)
Entity Type:Individual
Prefix:
First Name:ANNELYSSA
Middle Name:LEE
Last Name:MASSIE
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:PO BOX 2843
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-2843
Mailing Address - Country:US
Mailing Address - Phone:907-414-8400
Mailing Address - Fax:
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7017
Practice Address - Country:US
Practice Address - Phone:907-376-8020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK101662OtherSTATE OF ALASKA, DEPARTMENT OF COMERCE