Provider Demographics
NPI:1154619799
Name:KAMMARADA, MISTY (LAC, MSTOM)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:KAMMARADA
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 1:29 N LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2747
Mailing Address - Country:US
Mailing Address - Phone:732-859-6957
Mailing Address - Fax:
Practice Address - Street 1:581 5TH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-8407
Practice Address - Country:US
Practice Address - Phone:718-965-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004629171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist