Healthcare Provider Details

I. General information

NPI: 1033638192
Provider Name (Legal Business Name): ANNA MARIE AGONCILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 09/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 ALTA ARDEN EXPY
SACRAMENTO CA
95825-2103
US

IV. Provider business mailing address

8400 DARA WAY
SACRAMENTO CA
95828-6000
US

V. Phone/Fax

Practice location:
  • Phone: 916-481-5500
  • Fax:
Mailing address:
  • Phone: 916-544-1566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA4050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: