Provider Demographics
NPI:1073149498
Name:WYINDON, ANTONIA CELESTINE
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:CELESTINE
Last Name:WYINDON
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 1:3756 SANTA ROSALIA DR STE 424
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3614
Mailing Address - Country:US
Mailing Address - Phone:805-991-7615
Mailing Address - Fax:
Practice Address - Street 1:3756 SANTA ROSALIA DR STE 424
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3614
Practice Address - Country:US
Practice Address - Phone:805-991-7615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes172V00000XOther Service ProvidersCommunity Health Worker