Provider Demographics
NPI:1518531557
Name:LOO, CORINNA NICOLE (LAC)
Entity Type:Individual
Prefix:
First Name:CORINNA
Middle Name:NICOLE
Last Name:LOO
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 1:2191 EL SERENO AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-5632
Mailing Address - Country:US
Mailing Address - Phone:925-984-4124
Mailing Address - Fax:
Practice Address - Street 1:427 S MARENGO AVE STE 7
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3134
Practice Address - Country:US
Practice Address - Phone:925-984-4124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18834171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty