Provider Demographics
NPI:1457622607
Name:MA, CONNIE LYNN (LAC, MSTOM)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LYNN
Last Name:MA
Suffix:
Gender:F
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HICKS ST
Mailing Address - Street 2:APT 17M
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1658
Mailing Address - Country:US
Mailing Address - Phone:917-517-8220
Mailing Address - Fax:
Practice Address - Street 1:1 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5802
Practice Address - Country:US
Practice Address - Phone:917-517-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004749-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist