MEDICARE: MOMILANI DEANN CORONEL STASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	38921	TX

General Provider Information

NPI Number	:	1104326255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOMILANI DEANN CORONEL STASSISTANT

Provider Business Mailing Address
First Line	:	PO BOX 177545
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75017-7545
Country	:	US
Telephone Number	:	469-990-6318
Fax Number	:

Provider Business Practice Location Address
First Line	:	1613 WILDERNESS TRL
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-2028
Country	:	US
Telephone Number	:	469-990-6318
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2018
Last Update Date	:	02/15/2018

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