Provider Demographics
NPI:1407546237
Name:KINLAW, DOREVA R (ESTHETICIAN)
Entity type:Individual
Prefix:
First Name:DOREVA
Middle Name:R
Last Name:KINLAW
Suffix:
Gender:F
Credentials:ESTHETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 GRAND CONCOURSE
Mailing Address - Street 2:2ND FL
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-1706
Mailing Address - Country:US
Mailing Address - Phone:347-928-2175
Mailing Address - Fax:
Practice Address - Street 1:598 GRAND CONCOURSE
Practice Address - Street 2:2ND FL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-1706
Practice Address - Country:US
Practice Address - Phone:347-928-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAEE-23-00186174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist