Healthcare Provider Details

I. General information

NPI: 1538706064
Provider Name (Legal Business Name): MARIA-RENEE J COLDAGELLI MS LCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GATEWAY BLVD STE 380
SOUTH SAN FRANCISCO CA
94080-7420
US

IV. Provider business mailing address

19611 N 64TH LN
GLENDALE AZ
85308-7048
US

V. Phone/Fax

Practice location:
  • Phone: 776-880-9928
  • Fax:
Mailing address:
  • Phone: 708-953-9170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: