Provider Demographics
NPI:1407380454
Name:CAMPBELL, VANESSA (LMT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:CAMPBELL
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 876214
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-6214
Mailing Address - Country:US
Mailing Address - Phone:907-360-7444
Mailing Address - Fax:
Practice Address - Street 1:613 S KNIK GOOSE BAY RD STE D
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8090
Practice Address - Country:US
Practice Address - Phone:907-376-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK103986225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist