Provider Demographics
NPI:1437590379
Name:MA, SERENA LEE (ND, LAC)
Entity Type:Individual
Prefix:DR
First Name:SERENA
Middle Name:LEE
Last Name:MA
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 BROADWAY RM 1009
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2609
Mailing Address - Country:US
Mailing Address - Phone:212-995-8880
Mailing Address - Fax:646-478-9397
Practice Address - Street 1:636 BROADWAY RM 1009
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2609
Practice Address - Country:US
Practice Address - Phone:212-995-8880
Practice Address - Fax:646-478-9397
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT64021175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath