Healthcare Provider Details

I. General information

NPI: 1972947331
Provider Name (Legal Business Name): ROXANNE ISSURDATT LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8555 16TH ST STE 402
SILVER SPRING MD
20910-2802
US

IV. Provider business mailing address

63 VICTOR ST NE
WASHINGTON DC
20011-4939
US

V. Phone/Fax

Practice location:
  • Phone: 202-200-1220
  • Fax:
Mailing address:
  • Phone: 202-200-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02041
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: