Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 007822 | CT |
NPI | 1992978787 |
---|---|
Provider Name | Miss Jessica Grace Domingo Natividad |
First Address | Ellicott City, MD 21043-3655 |
Second Address | Ellicott City, MD 21043-3655 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2008 |
Last Update Date | 11/04/2008 |