Provider Demographics
NPI:1891398764
Name:WANG, JINGLEI
Entity Type:Individual
Prefix:
First Name:JINGLEI
Middle Name:
Last Name:WANG
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 1:44075 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4871
Mailing Address - Country:US
Mailing Address - Phone:760-772-2969
Mailing Address - Fax:760-772-5070
Practice Address - Street 1:43100 PALM ROYALE DR APT 623
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7996
Practice Address - Country:US
Practice Address - Phone:626-675-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist