Provider Demographics
NPI:1841941333
Name:WIGGINS, KENDREA R
Entity type:Individual
Prefix:MS
First Name:KENDREA
Middle Name:R
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 1:667 EMERALD AVE APT P
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-5014
Mailing Address - Country:US
Mailing Address - Phone:619-301-9577
Mailing Address - Fax:
Practice Address - Street 1:1963 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2394
Practice Address - Country:US
Practice Address - Phone:619-233-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local