Provider Demographics
NPI:1821363763
Name:PROVITOLA, GLORIA (L AC)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:
Last Name:PROVITOLA
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W 95TH ST
Mailing Address - Street 2:APT 2B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6103
Mailing Address - Country:US
Mailing Address - Phone:917-502-4566
Mailing Address - Fax:
Practice Address - Street 1:448 W 57TH ST
Practice Address - Street 2:HEALTH ON 57--GARDEN LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3055
Practice Address - Country:US
Practice Address - Phone:917-502-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-10
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004415171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist