Provider Demographics
NPI:1457984239
Name:WIGGINS, KATHERINE NAOMI
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NAOMI
Last Name:WIGGINS
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 1:6530 LA CONTENTA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7313
Mailing Address - Country:US
Mailing Address - Phone:760-297-2480
Mailing Address - Fax:
Practice Address - Street 1:72724 29 PALMS HWY STE 103
Practice Address - Street 2:
Practice Address - City:29 PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2459
Practice Address - Country:US
Practice Address - Phone:760-367-5906
Practice Address - Fax:866-732-0113
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95016259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program