Provider Demographics
NPI:1578921904
Name:ALDEA, KIARRA DOMENIQUE CANEDA
Entity Type:Individual
Prefix:MISS
First Name:KIARRA DOMENIQUE
Middle Name:CANEDA
Last Name:ALDEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3220
Mailing Address - Country:US
Mailing Address - Phone:912-228-2707
Mailing Address - Fax:
Practice Address - Street 1:21008 NORTHERN BLVD
Practice Address - Street 2:STE 1
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3211
Practice Address - Country:US
Practice Address - Phone:347-408-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP00591225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist