Provider Demographics
NPI:1558188631
Name:VAN TASSELL, ELISE NICOLE
Entity type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:NICOLE
Last Name:VAN TASSELL
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 1:476 HERITAGE PARK BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5679
Mailing Address - Country:US
Mailing Address - Phone:801-841-1222
Mailing Address - Fax:208-444-9804
Practice Address - Street 1:476 HERITAGE PARK BLVD STE 205
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5679
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:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist