Provider Demographics
NPI:1790905354
Name:WAN, CHENXIN (LAC)
Entity Type:Individual
Prefix:MISS
First Name:CHENXIN
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:172 KELLER ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2900
Mailing Address - Country:US
Mailing Address - Phone:707-762-9111
Mailing Address - Fax:
Practice Address - Street 1:172 KELLER ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2900
Practice Address - Country:US
Practice Address - Phone:707-762-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 10674171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist