Provider Demographics
NPI:1942970264
Name:WAKEFIELD, MAIZIE LYNN
Entity Type:Individual
Prefix:
First Name:MAIZIE
Middle Name:LYNN
Last Name:WAKEFIELD
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 1:5187 COLLEGE AVE
Mailing Address - Street 2:VILLA ALVARADO E233
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115
Mailing Address - Country:US
Mailing Address - Phone:208-440-0546
Mailing Address - Fax:
Practice Address - Street 1:5187 COLLEGE AVE
Practice Address - Street 2:VILLA ALVARADO E233
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115
Practice Address - Country:US
Practice Address - Phone:208-440-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty