Provider Demographics
NPI:1114097029
Name:FANG, JUDY QIN (LAC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:QIN
Last Name:FANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WATERSIDE CLEARING
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01718-1013
Mailing Address - Country:US
Mailing Address - Phone:978-929-9220
Mailing Address - Fax:
Practice Address - Street 1:256 GREAT RD
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1916
Practice Address - Country:US
Practice Address - Phone:978-486-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208945171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist