Provider Demographics
NPI:1972961936
Name:WINGERT, KATHLEEN ROSE (BCN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:WINGERT
Suffix:
Gender:F
Credentials:BCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7545 IRVINE CENTER DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618
Mailing Address - Country:US
Mailing Address - Phone:949-393-4219
Mailing Address - Fax:
Practice Address - Street 1:7545 IRVINE CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2932
Practice Address - Country:US
Practice Address - Phone:949-393-4219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5661174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist