Provider Demographics
NPI:1790278356
Name:VANITY: AESTHETICS, DERMATOLOGY & WELLNESS, LLC
Entity Type:Organization
Organization Name:VANITY: AESTHETICS, DERMATOLOGY & WELLNESS, LLC
Other - Org Name:VANITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JESIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:904-716-8955
Mailing Address - Street 1:431 W 7TH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3500
Mailing Address - Country:US
Mailing Address - Phone:907-250-2511
Mailing Address - Fax:888-908-9442
Practice Address - Street 1:431 W 7TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3500
Practice Address - Country:US
Practice Address - Phone:907-250-2511
Practice Address - Fax:888-908-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPADA1252207Q00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty