Healthcare Provider Details

I. General information

NPI: 1376215210
Provider Name (Legal Business Name): FONDA NANNETTE CORMIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15632 DOBBS PEAK LN
FONTANA CA
92336-4560
US

IV. Provider business mailing address

15632 DOBBS PEAK LN
FONTANA CA
92336-4560
US

V. Phone/Fax

Practice location:
  • Phone: 470-613-1093
  • Fax:
Mailing address:
  • Phone: 909-455-6531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number119737
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: