Provider Demographics
NPI:1548885163
Name:CARLSON, VANESSA (ATC)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12122 GINAMI ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-2551
Mailing Address - Country:US
Mailing Address - Phone:406-861-3644
Mailing Address - Fax:
Practice Address - Street 1:12350 INDUSTRY WAY STE 110
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-4301
Practice Address - Country:US
Practice Address - Phone:907-336-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1352242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer