1134453178 NPI number — NINETTE FONSECA-CHICCA MS SPEECH AND LANGUAGE PATHOLOGIST-CCC A PROFES

Table of content: (NPI 1134453178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134453178 NPI number — NINETTE FONSECA-CHICCA MS SPEECH AND LANGUAGE PATHOLOGIST-CCC A PROFES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NINETTE FONSECA-CHICCA MS SPEECH AND LANGUAGE PATHOLOGIST-CCC A PROFES
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1134453178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2430 SONOMA MOUNTAIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETALUMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94954-9283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-364-6075
Provider Business Mailing Address Fax Number:
707-795-5709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1295 PETALUMA BLVD N STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94952-6530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-364-6075
Provider Business Practice Location Address Fax Number:
707-795-5709
Provider Enumeration Date:
09/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHICCA
Authorized Official First Name:
NINETTE
Authorized Official Middle Name:
FONSECA
Authorized Official Title or Position:
PRESIDENT/SPEECH PATHOLOGIST
Authorized Official Telephone Number:
707-364-6075

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SP17198 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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