Provider Demographics
NPI:1891360970
Name:ADZAGAH, MENDOCINO NICOLE PEACOCK (MS)
Entity Type:Individual
Prefix:
First Name:MENDOCINO
Middle Name:NICOLE PEACOCK
Last Name:ADZAGAH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MENDY
Other - Middle Name:
Other - Last Name:ADZAGAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5770 S FASHION BLVD
Mailing Address - Street 2:BLDG #5, SUITE 210
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6330
Mailing Address - Country:US
Mailing Address - Phone:801-314-5241
Mailing Address - Fax:
Practice Address - Street 1:5770 S FASHION BOULEVARD
Practice Address - Street 2:BUILDING 5 SUITE 210
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:833-577-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCF7205235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
.OtherNONE