Provider Demographics
NPI:1023495629
Name:VAN DINE, ANNA LIZA (LAC)
Entity type:Individual
Prefix:
First Name:ANNA LIZA
Middle Name:
Last Name:VAN DINE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ANNA LIZA
Other - Middle Name:ENDENO
Other - Last Name:ESTROPIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2636 17TH AVE # 112
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1808
Mailing Address - Country:US
Mailing Address - Phone:855-946-9264
Mailing Address - Fax:855-826-3463
Practice Address - Street 1:2801 MISSION ST. EXT
Practice Address - Street 2:SUITE 2805
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060
Practice Address - Country:US
Practice Address - Phone:855-946-9264
Practice Address - Fax:855-826-3463
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-03
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16589171100000X
CA28538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist