Provider Demographics
NPI:1083045496
Name:SMITH, WANDA ELAINE (ADMINISTRATOR)
Entity Type:Individual
Prefix:MISS
First Name:WANDA
Middle Name:ELAINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 E. LANCASTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535
Mailing Address - Country:US
Mailing Address - Phone:661-992-6371
Mailing Address - Fax:855-631-0360
Practice Address - Street 1:1046 E LANCASTER BLVD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-2752
Practice Address - Country:US
Practice Address - Phone:661-992-6371
Practice Address - Fax:855-631-0360
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197602356310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility