Provider Demographics
NPI:1790214849
Name:ROMAN, LEYDI VIVIANA (COTA)
Entity Type:Individual
Prefix:
First Name:LEYDI
Middle Name:VIVIANA
Last Name:ROMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 SAUNDERS ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2037
Mailing Address - Country:US
Mailing Address - Phone:917-815-1349
Mailing Address - Fax:
Practice Address - Street 1:6307 SAUNDERS ST APT 1A
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2037
Practice Address - Country:US
Practice Address - Phone:917-815-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist