Provider Demographics
NPI:1841317609
Name:WANGEN, KERRY ELLEN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:ELLEN
Last Name:WANGEN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 THE CITY DR S BLDG 3
Mailing Address - Street 2:DEPARTMENT OF PSYCHIATRY
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3201
Mailing Address - Country:US
Mailing Address - Phone:714-456-5770
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S BLDG 3
Practice Address - Street 2:DEPARTMENT OF PSYCHIATRY
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA964992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry