Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 933 | NE |
NPI | 1003222530 |
---|---|
Provider Name | Fanny Bristol |
First Address | Alliance, NE 69301-0313 |
Second Address | Alliance, NE 69301-3600 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2014 |
Last Update Date | 03/07/2014 |