Provider Demographics
NPI:1952714347
Name:WUNDER, MARY RENEE (LVN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:RENEE
Last Name:WUNDER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20739 LYCOMING ST SPC 22
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91789-7322
Mailing Address - Country:US
Mailing Address - Phone:909-753-9807
Mailing Address - Fax:
Practice Address - Street 1:801 E CHAPMAN AVE
Practice Address - Street 2:#203
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3839
Practice Address - Country:US
Practice Address - Phone:714-680-8268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA255724164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse