Provider Demographics
NPI:1104231380
Name:GITTLEIN, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GITTLEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S BEGICH DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7619
Mailing Address - Country:US
Mailing Address - Phone:907-414-8995
Mailing Address - Fax:
Practice Address - Street 1:301 S BEGICH DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7619
Practice Address - Country:US
Practice Address - Phone:907-414-8995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6170164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse