Healthcare Provider Details

I. General information

NPI: 1467214429
Provider Name (Legal Business Name): VANESSA WESLEY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18662 SW BOONES FERRY RD
TUALATIN OR
97062-8435
US

IV. Provider business mailing address

18662 SW BOONES FERRY RD
TUALATIN OR
97062-8435
US

V. Phone/Fax

Practice location:
  • Phone: 971-808-3058
  • Fax:
Mailing address:
  • Phone: 971-808-3058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC208631
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: