Provider Demographics
NPI:1851688204
Name:CLARKE, VANESSA M (MA60234012)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:M
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MA60234012
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11509 65TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-2848
Mailing Address - Country:US
Mailing Address - Phone:253-335-2028
Mailing Address - Fax:
Practice Address - Street 1:601 S PINE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2793
Practice Address - Country:US
Practice Address - Phone:253-396-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60234012225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist