Provider Demographics
NPI:1134655517
Name:GUADAGNINO, TALLULAH
Entity type:Individual
Prefix:
First Name:TALLULAH
Middle Name:
Last Name:GUADAGNINO
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 1:2703 SCUTT MOUNTAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:BOVINA CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13740
Mailing Address - Country:US
Mailing Address - Phone:607-221-3082
Mailing Address - Fax:
Practice Address - Street 1:2703 SCUTT MOUNTAIN ROAD
Practice Address - Street 2:
Practice Address - City:BOVINA CENTER
Practice Address - State:NY
Practice Address - Zip Code:13740
Practice Address - Country:US
Practice Address - Phone:607-221-3082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003119-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer