Provider Demographics
NPI:1831634005
Name:VANG, MARISA
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:VANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:VANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNMT
Mailing Address - Street 1:5936 BEARD AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2630
Mailing Address - Country:US
Mailing Address - Phone:763-402-1013
Mailing Address - Fax:
Practice Address - Street 1:5936 BEARD AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2630
Practice Address - Country:US
Practice Address - Phone:763-402-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist