Provider Demographics
NPI:1518439793
Name:ISIAHO, TERESIA WANJA
Entity Type:Individual
Prefix:
First Name:TERESIA
Middle Name:WANJA
Last Name:ISIAHO
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 1:986 LUTHER DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-5262
Mailing Address - Country:US
Mailing Address - Phone:757-842-1402
Mailing Address - Fax:
Practice Address - Street 1:986 LUTHER DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-5262
Practice Address - Country:US
Practice Address - Phone:757-842-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95154104163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty