Provider Demographics
NPI:1982320156
Name:JONTIFF, LOLA (RAD T)
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:JONTIFF
Suffix:
Gender:F
Credentials:RAD T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 1/2 HELIOTROPE AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625
Mailing Address - Country:US
Mailing Address - Phone:786-683-6166
Mailing Address - Fax:
Practice Address - Street 1:418 1/2 HELIOTROPE AVE
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625
Practice Address - Country:US
Practice Address - Phone:786-683-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNAMedicaid