Provider Demographics
NPI:1619267028
Name:VANN, ADLEY AARON (LMT)
Entity Type:Individual
Prefix:MR
First Name:ADLEY
Middle Name:AARON
Last Name:VANN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 E 11TH PL
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-3551
Mailing Address - Country:US
Mailing Address - Phone:219-256-2614
Mailing Address - Fax:
Practice Address - Street 1:4317 E 11TH PL
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-3551
Practice Address - Country:US
Practice Address - Phone:219-256-2614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20903113225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist