Provider Demographics
NPI:1588190391
Name:ATWELL, ANNETTA JEAN (LMT)
Entity type:Individual
Prefix:MRS
First Name:ANNETTA
Middle Name:JEAN
Last Name:ATWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2728 DEEPWOODS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6605
Mailing Address - Country:US
Mailing Address - Phone:907-888-2148
Mailing Address - Fax:907-451-9168
Practice Address - Street 1:1221 NOBLE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4961
Practice Address - Country:US
Practice Address - Phone:907-456-4234
Practice Address - Fax:907-451-9168
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist