Healthcare Provider Details

I. General information

NPI: 1053698977
Provider Name (Legal Business Name): CYNTHIA ALICE NOLAN RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2011
Last Update Date: 11/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 ESTATES DR
FAIRFIELD CA
94533-9712
US

IV. Provider business mailing address

3310 MONTE VISTA AVE
DAVIS CA
95618-4929
US

V. Phone/Fax

Practice location:
  • Phone: 707-432-1218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT5587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: