Healthcare Provider Details

I. General information

NPI: 1295261832
Provider Name (Legal Business Name): TINAMARIE GNOLFO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 CREEDMOOR RD
RALEIGH NC
27612-6352
US

IV. Provider business mailing address

5505 CREEDMOOR RD
RALEIGH NC
27612-6352
US

V. Phone/Fax

Practice location:
  • Phone: 919-349-8512
  • Fax:
Mailing address:
  • Phone: 919-349-8512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number5533
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: