Healthcare Provider Details

I. General information

NPI: 1568115814
Provider Name (Legal Business Name): MRS. CHERIE ANN VISCONTI I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 MANOR RD
FAIRFAX CA
94930-1407
US

IV. Provider business mailing address

PO BOX 2031
SAN ANSELMO CA
94979-2031
US

V. Phone/Fax

Practice location:
  • Phone: 415-509-6414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-306128
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-306128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: