Provider Demographics
NPI:1841718178
Name:ANZALONE, EDDIE DEAN (MA60756602)
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:DEAN
Last Name:ANZALONE
Suffix:
Gender:M
Credentials:MA60756602
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SW 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-3032
Mailing Address - Country:US
Mailing Address - Phone:707-771-0616
Mailing Address - Fax:
Practice Address - Street 1:17030 SE 1ST ST STE 102
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8514
Practice Address - Country:US
Practice Address - Phone:360-604-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60756602225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist