Provider Demographics
NPI:1407397151
Name:DE LA CRUZ, ROSANNA (LAC)
Entity Type:Individual
Prefix:
First Name:ROSANNA
Middle Name:
Last Name:DE LA CRUZ
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 1:708 W 171ST ST
Mailing Address - Street 2:APT. SUPER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2819
Mailing Address - Country:US
Mailing Address - Phone:347-657-4386
Mailing Address - Fax:
Practice Address - Street 1:708 W 171ST ST
Practice Address - Street 2:APT. SUPER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2819
Practice Address - Country:US
Practice Address - Phone:347-657-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005834-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist