Provider Demographics
NPI:1740769157
Name:WAILES, JULIE EMMA SWERDLOW
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:EMMA SWERDLOW
Last Name:WAILES
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 1:605 ESTHER WAY
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 COMMERCENTER E STE 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3423
Practice Address - Country:US
Practice Address - Phone:909-891-1913
Practice Address - Fax:909-884-0810
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95009906363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner