Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 33804 | CA |
N | 225100000X | Physical Therapist | 5501012517 | MI |
NPI | 1003005414 |
---|---|
Provider Name | Joan Luna Vicente |
First Address | Milwaukie, OR 97222 |
Second Address | Milwaukie, OR 97222 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/10/2007 |
Last Update Date | 22/10/2007 |