Healthcare Provider Details

I. General information

NPI: 1851745822
Provider Name (Legal Business Name): JENNIFER NITOLLAMA PT, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11402 S CHURCH ST
ORANGE CA
92869-2620
US

IV. Provider business mailing address

11402 S CHURCH ST
ORANGE CA
92869-2620
US

V. Phone/Fax

Practice location:
  • Phone: 714-651-6008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number36549
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number36549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: