Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 24079 | CA |
NPI | 1063653459 |
---|---|
Provider Name | Anne Maria Leistikow |
First Address | San Diego, CA 92102-4541 |
Second Address | San Diego, CA 92102-4541 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/03/2009 |
Last Update Date | 13/03/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
W5352 | UPIN (01) | CA |