Provider Demographics
NPI:1609265537
Name:STINSON LOLLICH, NANCY (PTA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:STINSON LOLLICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PAINTER ST
Mailing Address - Street 2:
Mailing Address - City:RIO DELL
Mailing Address - State:CA
Mailing Address - Zip Code:95562-1319
Mailing Address - Country:US
Mailing Address - Phone:707-599-9275
Mailing Address - Fax:
Practice Address - Street 1:2321 NEWBURG ROAD
Practice Address - Street 2:FORTUNA REHABILITATION AND WELLNESS
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540
Practice Address - Country:US
Practice Address - Phone:707-725-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA316225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant