Provider Demographics
NPI:1902316201
Name:MAI NGAM, KESARA (LMT)
Entity Type:Individual
Prefix:
First Name:KESARA
Middle Name:
Last Name:MAI NGAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W OAK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3808
Mailing Address - Country:US
Mailing Address - Phone:863-812-9388
Mailing Address - Fax:
Practice Address - Street 1:117 WEST OAK DRIVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:863-812-9388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA78493225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist