Provider Demographics
NPI:1902440829
Name:IWANICKI, CHRISTIAN QUINN
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:QUINN
Last Name:IWANICKI
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 1:330 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-3615
Mailing Address - Country:US
Mailing Address - Phone:707-592-6826
Mailing Address - Fax:
Practice Address - Street 1:429 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-4530
Practice Address - Country:US
Practice Address - Phone:707-447-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist