Healthcare Provider Details

I. General information

NPI: 1538753223
Provider Name (Legal Business Name): PATTY LO KALLAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 7TH AVE FL 14
NEW YORK NY
10018-4603
US

IV. Provider business mailing address

9805 63RD RD APT 12N
REGO PARK NY
11374-1723
US

V. Phone/Fax

Practice location:
  • Phone: 212-768-7979
  • Fax:
Mailing address:
  • Phone: 917-340-1334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number022906-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: