Provider Demographics
NPI:1669171153
Name:CASSANGUIR, NADIA JOLIE
Entity type:Individual
Prefix:
First Name:NADIA
Middle Name:JOLIE
Last Name:CASSANGUIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NADIA
Other - Middle Name:
Other - Last Name:KASSONGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12379 W WHYMAN AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1241
Mailing Address - Country:US
Mailing Address - Phone:623-313-0532
Mailing Address - Fax:
Practice Address - Street 1:12379 W WHYMAN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1241
Practice Address - Country:US
Practice Address - Phone:623-313-0532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9557460385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child