Provider Demographics
NPI:1144742545
Name:LE FRIDGE-WILSON, STARLA EVONNE
Entity Type:Individual
Prefix:
First Name:STARLA
Middle Name:EVONNE
Last Name:LE FRIDGE-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 1:2010 ZONAL AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1026
Mailing Address - Country:US
Mailing Address - Phone:323-226-3511
Mailing Address - Fax:323-226-4948
Practice Address - Street 1:2010 ZONAL AVE FL 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1026
Practice Address - Country:US
Practice Address - Phone:323-226-3511
Practice Address - Fax:323-226-4948
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA559544163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care