Healthcare Provider Details

I. General information

NPI: 1154042216
Provider Name (Legal Business Name): LUCELIA CARDONA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2763 BELLA CIR
SANTA ROSA CA
95407-2793
US

IV. Provider business mailing address

9 ASCOT DR
SANTA ROSA CA
95403-1424
US

V. Phone/Fax

Practice location:
  • Phone: 707-888-7054
  • Fax:
Mailing address:
  • Phone: 707-888-7054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: