Provider Demographics
NPI:1336917921
Name:COLE, GENESIS (MS)
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:GENESIS
Other - Middle Name:
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:900 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5853
Mailing Address - Country:US
Mailing Address - Phone:530-273-2244
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:530-273-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker