Healthcare Provider Details

I. General information

NPI: 1861850364
Provider Name (Legal Business Name): ELAN INEZ VAN VLACK MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAN INEZ LITTLEJOHN

II. Dates (important events)

Enumeration Date: 01/29/2016
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W BELTLINE HWY STE 207
MADISON WI
53713-2321
US

IV. Provider business mailing address

2501 W BELTLINE HWY STE 207
MADISON WI
53713-2321
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-7341
  • Fax: 608-417-5770
Mailing address:
  • Phone: 608-417-7341
  • Fax: 608-417-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: