Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 50519 | CA |
NPI | 1013524701 |
---|---|
Provider Name | Pettie Ontell |
First Address | Fontana, CA 92337-1526 |
Second Address | Fontana, CA 92337-1526 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2020 |
Last Update Date | 26/09/2020 |