Provider Demographics
NPI:1184791113
Name:LESAGE, AMY K (DACM, LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:LESAGE
Suffix:
Gender:F
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10391 HESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4432
Mailing Address - Country:US
Mailing Address - Phone:562-505-3346
Mailing Address - Fax:
Practice Address - Street 1:1122 BRISTOL ST STE 200
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7972
Practice Address - Country:US
Practice Address - Phone:949-631-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11261171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist