Provider Demographics
NPI:1356370084
Name:KWAN, GILDA OTILIA LEGACY (DOM)
Entity type:Individual
Prefix:
First Name:GILDA
Middle Name:OTILIA LEGACY
Last Name:KWAN
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 MASON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-6498
Mailing Address - Country:US
Mailing Address - Phone:813-657-2640
Mailing Address - Fax:813-657-2685
Practice Address - Street 1:4367 LYNX PAW TRL
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-7426
Practice Address - Country:US
Practice Address - Phone:813-657-2640
Practice Address - Fax:813-657-2685
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2219171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist