Provider Demographics
NPI:1760032791
Name:WITHINGHAM, EDIKA
Entity Type:Individual
Prefix:
First Name:EDIKA
Middle Name:
Last Name:WITHINGHAM
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 1:16075 GERANIUM CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-7293
Mailing Address - Country:US
Mailing Address - Phone:951-345-2646
Mailing Address - Fax:
Practice Address - Street 1:3148 BELVEDERE DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3205
Practice Address - Country:US
Practice Address - Phone:951-788-0940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider