Provider Demographics
NPI:1922445170
Name:WONG, LANI ROSE (LICAC, MAC)
Entity Type:Individual
Prefix:MS
First Name:LANI
Middle Name:ROSE
Last Name:WONG
Suffix:
Gender:F
Credentials:LICAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-7721
Mailing Address - Country:US
Mailing Address - Phone:781-366-0881
Mailing Address - Fax:
Practice Address - Street 1:47 3RD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1265
Practice Address - Country:US
Practice Address - Phone:781-366-0881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA257121171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist