Provider Demographics
NPI:1619346426
Name:VANOSDOL, MCKENSIE ELLYN
Entity Type:Individual
Prefix:
First Name:MCKENSIE
Middle Name:ELLYN
Last Name:VANOSDOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 PERSIMMON DR
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-2459
Mailing Address - Country:US
Mailing Address - Phone:812-592-7725
Mailing Address - Fax:
Practice Address - Street 1:475 PERSIMMON DR
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-2459
Practice Address - Country:US
Practice Address - Phone:812-592-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer