Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT3474 | NM |
NPI | 1003423872 |
---|---|
Provider Name | Laura Jolly |
First Address | Santa Fe, NM 87505-3314 |
Second Address | Santa Fe, NM 87505-3314 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2020 |
Last Update Date | 25/09/2020 |