Provider Demographics
NPI:1952686511
Name:ANDALORO, MARISSA LEE (LAC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEE
Last Name:ANDALORO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16852 REDWING LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3871
Mailing Address - Country:US
Mailing Address - Phone:714-815-7488
Mailing Address - Fax:
Practice Address - Street 1:16852 REDWING LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3871
Practice Address - Country:US
Practice Address - Phone:714-815-7488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14434171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist