Provider Demographics
NPI:1871483990
Name:LEWALLEN, VANESSA (LAC)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:LEWALLEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 WILDLIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-5436
Mailing Address - Country:US
Mailing Address - Phone:912-507-5150
Mailing Address - Fax:
Practice Address - Street 1:2886 S 8TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4462
Practice Address - Country:US
Practice Address - Phone:904-468-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4670171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist