Provider Demographics
NPI:1508156365
Name:WEST, LA WANDA (LVN)
Entity Type:Individual
Prefix:
First Name:LA WANDA
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22800 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-1874
Mailing Address - Country:US
Mailing Address - Phone:951-312-3723
Mailing Address - Fax:
Practice Address - Street 1:22800 DOWNING ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-1874
Practice Address - Country:US
Practice Address - Phone:951-312-3723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN186985164X00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No372600000XNursing Service Related ProvidersAdult Companion