MEDICARE: MS. NICOLE WETTACH-FARIAS

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	104100000X	Social Worker	127045	CA

General Provider Information

NPI Number	:	1417325051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE WETTACH-FARIAS

Provider Business Mailing Address
First Line	:	7811 BERNICE CT
Second Line	:
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928-4021
Country	:	US
Telephone Number	:	707-977-8611
Fax Number	:

Provider Business Practice Location Address
First Line	:	2455 BENNETT VALLEY RD STE B209
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-5669
Country	:	US
Telephone Number	:	707-224-8266
Fax Number	:

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

Provider Enumeration Date	:	09/14/2015
Last Update Date	:	11/27/2024

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