Provider Demographics
NPI:1558188631
Name:VAN TASSELL, ELISE NICOLE (LMT)
Entity type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:NICOLE
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 MCCORMICK WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7274
Mailing Address - Country:US
Mailing Address - Phone:801-841-1222
Mailing Address - Fax:208-444-9804
Practice Address - Street 1:887 MCCORMICK WAY STE 1
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7274
Practice Address - Country:US
Practice Address - Phone:801-841-1222
Practice Address - Fax:208-444-9804
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT174400000X
UT14239616-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist