Healthcare Provider Details

I. General information

NPI: 1285511931
Provider Name (Legal Business Name): AMANDA ALLISON NOONAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2025
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 E COVELL BLVD
DAVIS CA
95616-1366
US

IV. Provider business mailing address

2100 STANDIFORD AVE STE 12
MODESTO CA
95350-6522
US

V. Phone/Fax

Practice location:
  • Phone: 510-214-2479
  • Fax:
Mailing address:
  • Phone: 510-214-2479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: