Provider Demographics
NPI:1073914198
Name:WILSON, LA QUANDA
Entity Type:Individual
Prefix:
First Name:LA QUANDA
Middle Name:
Last Name:WILSON
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 1:9564 MAIE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-2349
Mailing Address - Country:US
Mailing Address - Phone:310-597-3779
Mailing Address - Fax:
Practice Address - Street 1:4300 LONG BEACH BLVD STE 700
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2000
Practice Address - Country:US
Practice Address - Phone:310-783-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program