Provider Demographics
NPI:1306364807
Name:HALLSTROM, ANNELIE JEANETTE (LAC)
Entity Type:Individual
Prefix:
First Name:ANNELIE
Middle Name:JEANETTE
Last Name:HALLSTROM
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 1:1308 FRANKLIN ST APT C
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2674
Mailing Address - Country:US
Mailing Address - Phone:310-367-6854
Mailing Address - Fax:
Practice Address - Street 1:1308 FRANKLIN ST APT C
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2674
Practice Address - Country:US
Practice Address - Phone:310-367-6854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17715171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist