Provider Demographics
NPI:1558685214
Name:FUGO ZIBELMAN, NICOLE (LAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FUGO ZIBELMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 DEBRA DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5425
Mailing Address - Country:US
Mailing Address - Phone:415-295-6108
Mailing Address - Fax:415-226-0170
Practice Address - Street 1:616 PETALUMA BLVD N STE B
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2847
Practice Address - Country:US
Practice Address - Phone:415-295-6108
Practice Address - Fax:415-226-0170
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK000965171100000X
CAAC15158171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist