Provider Demographics
NPI:1154831550
Name:CARDONA, ACTAVIA MARISSA (LMT)
Entity Type:Individual
Prefix:
First Name:ACTAVIA
Middle Name:MARISSA
Last Name:CARDONA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 KUNKEL AVE
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-9337
Mailing Address - Country:US
Mailing Address - Phone:717-558-8228
Mailing Address - Fax:
Practice Address - Street 1:397 KUNKEL AVE
Practice Address - Street 2:
Practice Address - City:HUMMELSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17036-9337
Practice Address - Country:US
Practice Address - Phone:717-558-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA66694225700000X
PAMSG010374225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist