Provider Demographics
NPI:1538706684
Name:OTTAVIANO, LORI (LAC DIPLAC)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:
Last Name:OTTAVIANO
Suffix:
Gender:F
Credentials:LAC DIPLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 CROFT LN
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4112
Mailing Address - Country:US
Mailing Address - Phone:516-385-7661
Mailing Address - Fax:631-979-9634
Practice Address - Street 1:72 CROFT LN
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4112
Practice Address - Country:US
Practice Address - Phone:516-385-7661
Practice Address - Fax:631-979-9634
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006371-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist