Provider Demographics
NPI:1760182539
Name:WAMAGATTA, GRACE WANJIRU (RN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:WANJIRU
Last Name:WAMAGATTA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8256 CAMINO ALTO DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2438
Mailing Address - Country:US
Mailing Address - Phone:562-335-2658
Mailing Address - Fax:
Practice Address - Street 1:8256 CAMINO ALTO DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2438
Practice Address - Country:US
Practice Address - Phone:562-335-2658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95316549163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice