Provider Demographics
NPI:1255070140
Name:REQUIERON, WENNA KAE PASANA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:WENNA KAE
Middle Name:PASANA
Last Name:REQUIERON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36284 REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4382
Mailing Address - Country:US
Mailing Address - Phone:951-348-0995
Mailing Address - Fax:
Practice Address - Street 1:27393 YNEZ RD STE 153
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4605
Practice Address - Country:US
Practice Address - Phone:951-331-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33520235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33520OtherSPEECH PATHOLOGIST