Provider Demographics
NPI:1073214227
Name:NELLICKAL, MARGARET VANNIA
Entity Type:Individual
Prefix:MS
First Name:MARGARET VANNIA
Middle Name:
Last Name:NELLICKAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 ANTERO CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4646
Mailing Address - Country:US
Mailing Address - Phone:310-989-8132
Mailing Address - Fax:
Practice Address - Street 1:8265 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-373-1641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19653235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist