Provider Demographics
NPI:1073786190
Name:SOMODEVILLA, NANCY A
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:SOMODEVILLA
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 1:5469 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120
Mailing Address - Country:US
Mailing Address - Phone:901-761-0021
Mailing Address - Fax:
Practice Address - Street 1:5469 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-1928
Practice Address - Country:US
Practice Address - Phone:901-761-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP2145235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNSP2145OtherHEALTH RELATED BOARD