Provider Demographics
NPI:1558579425
Name:VANZANT, MARY KAY (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KAY
Last Name:VANZANT
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 1:4329 SE 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3629
Mailing Address - Country:US
Mailing Address - Phone:503-772-3632
Mailing Address - Fax:
Practice Address - Street 1:5311 N VANCOUVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2731
Practice Address - Country:US
Practice Address - Phone:503-281-0308
Practice Address - Fax:503-281-4691
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11464225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist