Provider Demographics
NPI:1407165616
Name:WILDE, LEILANI (PCD(DONA),CLC)
Entity Type:Individual
Prefix:MRS
First Name:LEILANI
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:PCD(DONA),CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13210 MEDALLION LN
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-5019
Mailing Address - Country:US
Mailing Address - Phone:619-922-0808
Mailing Address - Fax:619-328-5995
Practice Address - Street 1:13210 MEDALLION LN
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-5019
Practice Address - Country:US
Practice Address - Phone:619-922-0808
Practice Address - Fax:619-328-5995
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
CA11155412174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula