Provider Demographics
NPI:1902012651
Name:FRAGOMENI-NUTTALL, MARY LOU (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:FRAGOMENI-NUTTALL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5345 E FORT LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1312
Mailing Address - Country:US
Mailing Address - Phone:520-270-0830
Mailing Address - Fax:520-324-1610
Practice Address - Street 1:5345 E FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1312
Practice Address - Country:US
Practice Address - Phone:520-270-0830
Practice Address - Fax:520-324-1610
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0579235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist