Provider Demographics
NPI:1356749832
Name:WALDRAM, JUSTINE E (LM)
Entity type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:E
Last Name:WALDRAM
Suffix:
Gender:F
Credentials:LM
Other - Prefix:MISS
Other - First Name:JUSTINE
Other - Middle Name:E
Other - Last Name:MCMANIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4251 S HIGUERA ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7741
Mailing Address - Country:US
Mailing Address - Phone:805-994-0074
Mailing Address - Fax:
Practice Address - Street 1:4251 S HIGUERA ST STE 300
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7741
Practice Address - Country:US
Practice Address - Phone:805-994-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM 406176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife