Provider Demographics
NPI:1396014056
Name:MAISALA-MCDONNELL, HEINI (PT MOMT)
Entity type:Individual
Prefix:
First Name:HEINI
Middle Name:
Last Name:MAISALA-MCDONNELL
Suffix:
Gender:F
Credentials:PT MOMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 MACK BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4004
Mailing Address - Country:US
Mailing Address - Phone:907-347-0187
Mailing Address - Fax:
Practice Address - Street 1:2775 MACK BLVD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4004
Practice Address - Country:US
Practice Address - Phone:907-347-0187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK732225100000X
WA6253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist