Provider Demographics
NPI:1942521331
Name:REDISKE, ANITA AYN (LMP)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:AYN
Last Name:REDISKE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7514 VIRGINIA LN
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2169
Mailing Address - Country:US
Mailing Address - Phone:360-901-5882
Mailing Address - Fax:
Practice Address - Street 1:7612 NE HAZEL DELL AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8224
Practice Address - Country:US
Practice Address - Phone:360-694-1575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-19
Last Update Date:2010-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00016105225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist