Provider Demographics
NPI:1548733314
Name:PADILLA, AMELIA
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:PADILLA
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 1:5263 BEAUMONT WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-2861
Mailing Address - Country:US
Mailing Address - Phone:951-235-1617
Mailing Address - Fax:
Practice Address - Street 1:4650 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-9407
Practice Address - Country:US
Practice Address - Phone:707-546-0471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1244769225100000X
CA24652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist