Provider Demographics
NPI:1265131379
Name:WEST, WANDA LESLIE
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:LESLIE
Last Name:WEST
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 1:10480 NIGHTHAWK CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-2773
Mailing Address - Country:US
Mailing Address - Phone:951-733-6083
Mailing Address - Fax:
Practice Address - Street 1:10480 NIGHTHAWK CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-2773
Practice Address - Country:US
Practice Address - Phone:951-733-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20622895OtherKAISER
CA254030Medicaid