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General NPI Number Information
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NPI Number | 1750518460
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Entity Type | Individual
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Provider Name | LISA ELLEN GRAHAM MSTOM
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Gender | Female
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Dates
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Enumeration Date | 06/20/2009
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Last Update Date | 06/20/2009
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Provider Practice Location Address
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Address Line | 6301 SUNSET DR SUITE 201
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City | SOUTH MIAMI
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State | FL
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Zip | 33143-4818
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Country | US
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Telephone | 305-669-2715
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Fax |
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Provider Business Mailing Address
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Address Line | 5120 CARILLO ST
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City | CORAL GABLES
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State | FL
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Zip | 33146-2060
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Country | US
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Telephone | 305-740-5547
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AP2651
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License Number State | FL
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