Healthcare Provider Details

I. General information

NPI: 1588925077
Provider Name (Legal Business Name): FANNIE TAN KOA LIC.AC., DIPL.OM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 ELM ST SUITE 300B
SOMERVILLE MA
02144-2950
US

IV. Provider business mailing address

259 ELM ST SUITE 300B
SOMERVILLE MA
02144-2950
US

V. Phone/Fax

Practice location:
  • Phone: 617-294-9109
  • Fax:
Mailing address:
  • Phone: 617-294-9109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number253925
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number205
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: