Provider Demographics
NPI:1508118845
Name:JALANUGRAHA, WTIN (LVN)
Entity Type:Individual
Prefix:MR
First Name:WTIN
Middle Name:
Last Name:JALANUGRAHA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 VAN NUYS BLVD
Mailing Address - Street 2:APT 3
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3728
Mailing Address - Country:US
Mailing Address - Phone:818-784-7818
Mailing Address - Fax:
Practice Address - Street 1:UCLA STUDENT HEALTH SERVICES
Practice Address - Street 2:221 WESTWOOD PLAZA
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-825-4073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148439164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse