Provider Demographics
NPI:1609574086
Name:WAITARA, EDDAH WANGECI (RN,BSN)
Entity Type:Individual
Prefix:
First Name:EDDAH
Middle Name:WANGECI
Last Name:WAITARA
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2389 LEIGHTON WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8838
Mailing Address - Country:US
Mailing Address - Phone:626-404-3024
Mailing Address - Fax:
Practice Address - Street 1:2389 LEIGHTON WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-8838
Practice Address - Country:US
Practice Address - Phone:626-404-3024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA712085163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty