Provider Demographics
NPI:1205089299
Name:WAND, MICHAEL LEE (RN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEE
Last Name:WAND
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 EMDEN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4912
Mailing Address - Country:US
Mailing Address - Phone:310-518-5572
Mailing Address - Fax:
Practice Address - Street 1:1302 EMDEN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4912
Practice Address - Country:US
Practice Address - Phone:310-518-5572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA409904163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health