Provider Demographics
NPI:1720542293
Name:WONCIK, AUDREY (LVN)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WONCIK
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 1:18012 HIAWATHA ST APT 286
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3533
Mailing Address - Country:US
Mailing Address - Phone:818-430-6471
Mailing Address - Fax:
Practice Address - Street 1:4434 HARDING AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6123
Practice Address - Country:US
Practice Address - Phone:818-430-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA266349164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse