Provider Demographics
NPI:1043872351
Name:WILEY, RANDI RENEE (LVN)
Entity Type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:RENEE
Last Name:WILEY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 SAN GABRIEL PL STE C
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-2498
Mailing Address - Country:US
Mailing Address - Phone:562-222-1331
Mailing Address - Fax:562-222-1322
Practice Address - Street 1:5200 SAN GABRIEL PL STE C
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2498
Practice Address - Country:US
Practice Address - Phone:562-222-1331
Practice Address - Fax:562-222-1322
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA685417164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse