Basic Information
| Provider Information | |||||||||
| NPI: | 1588255822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILBERT | ||||||||
| FirstName: | VANESSA | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1744 E MCANDREWS RD STE D | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414140362 | ||||||||
| FaxNumber: | 5412002262 | ||||||||
| Practice Location | |||||||||
| Address1: | 2931 DOCTORS PARK DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419732551 | ||||||||
| FaxNumber: | 5419732835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2021 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 24734 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 24734 | 01 | OR | OREGON DEPT OF HEALTH | OTHER |