Provider Demographics
NPI:1073747820
Name:WAHDAN, LAILA (LAC)
Entity Type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:WAHDAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E CAMPBELL AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 W SAN FERNANDO ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-4815
Practice Address - Country:US
Practice Address - Phone:408-384-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12924171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist