Provider Demographics
NPI:1407351935
Name:MWANDAGA, JUDITH LEAH
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LEAH
Last Name:MWANDAGA
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 1:582 MANHATTAN WAY
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-8400
Mailing Address - Country:US
Mailing Address - Phone:714-858-1284
Mailing Address - Fax:
Practice Address - Street 1:582 MANHATTAN WAY
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-8400
Practice Address - Country:US
Practice Address - Phone:714-858-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA694652163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health