Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251G0304X | Physical Therapist - Geriatrics | 031426-1 | NY |
Y | 2251P0200X | Physical Therapist - Pediatrics | 031426-1 | NY |
NPI | 1053738542 |
---|---|
Provider Name | Jingle Candelasa |
First Address | Staten Island, NY 10301-3710 |
Second Address | Staten Island, NY 10301 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2014 |
Last Update Date | 24/03/2014 |