Provider Demographics
NPI:1497133185
Name:VANFOSSAN, GRETCHEN (LAC, MAC)
Entity Type:Individual
Prefix:MS
First Name:GRETCHEN
Middle Name:
Last Name:VANFOSSAN
Suffix:
Gender:F
Credentials:LAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8555 16TH ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-2816
Mailing Address - Country:US
Mailing Address - Phone:301-565-2700
Mailing Address - Fax:
Practice Address - Street 1:8555 16TH ST
Practice Address - Street 2:SUITE 402
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-2816
Practice Address - Country:US
Practice Address - Phone:301-565-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist