| NPI | 1710100888 |
|---|---|
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: LA 12053) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization (Licence: LA 12054) |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2010-10-05 |