Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 006972-1 | NY |
N | 225700000X | Massage Therapist | 006973-1 |
NPI | 1003307711 |
---|---|
Provider Name | Pamela Lee Walters |
First Address | Amityville, NY 11701-2705 |
Second Address | Amityville, NY 11701-2705 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2018 |
Last Update Date | 29/05/2018 |