Provider Demographics
NPI:1487859187
Name:STUDENNY, MARY (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:STUDENNY
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 1:12114 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3812
Mailing Address - Country:US
Mailing Address - Phone:310-403-2865
Mailing Address - Fax:
Practice Address - Street 1:12114 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3812
Practice Address - Country:US
Practice Address - Phone:310-403-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10555171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist