Provider Demographics
NPI:1225706096
Name:WELLINGTON, JOHNATHAN BRANDON
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:BRANDON
Last Name:WELLINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27882 DE LA VALLE DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-5917
Mailing Address - Country:US
Mailing Address - Phone:951-750-0117
Mailing Address - Fax:
Practice Address - Street 1:25400 ALESSANDRO BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4319
Practice Address - Country:US
Practice Address - Phone:951-750-0117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-05
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550006383251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health