=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003526864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDY GATTONI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2022
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000B S CENTER DR
-----------------------------------------------------
City | CLEARLAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95422-8458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-533-5829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1173 ELEVENTH ST
-----------------------------------------------------
City | LAKEPORT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95453-4113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-477-8730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------