Provider Demographics
NPI:1154117299
Name:HIETALA, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:HIETALA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5317 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1629
Mailing Address - Country:US
Mailing Address - Phone:218-576-3909
Mailing Address - Fax:
Practice Address - Street 1:5317 GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-1629
Practice Address - Country:US
Practice Address - Phone:218-576-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCLMT000620-2024225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist