Provider Demographics
NPI:1477029494
Name:AFFANDY, ALLISON DAMA
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:DAMA
Last Name:AFFANDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:ANNE
Other - Last Name:DAMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2210 NORTHWEST AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-3654
Mailing Address - Country:US
Mailing Address - Phone:517-256-9370
Mailing Address - Fax:
Practice Address - Street 1:2378 WOODLAKE DR STE 280
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6016
Practice Address - Country:US
Practice Address - Phone:517-256-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010178225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist