Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175F00000X | Naturopath | 12-1304 | AZ |
NPI | 1104182906 |
---|---|
Provider Name | Mrs. Kirstin Anna Correia |
First Address | Mesa, AZ 85277-0117 |
Second Address | Mesa, AZ 85215 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/04/2012 |
Last Update Date | 03/07/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12-1304 | LICENSE NUMBER (01) | AZ |