Provider Demographics
NPI:1952770448
Name:WEST, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:WEST
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:PO BOX 452103
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:90045-8527
Mailing Address - Country:US
Mailing Address - Phone:310-936-4621
Mailing Address - Fax:310-568-9583
Practice Address - Street 1:5150 CANDLEWOOD ST
Practice Address - Street 2:D20
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1925
Practice Address - Country:US
Practice Address - Phone:310-936-4621
Practice Address - Fax:310-568-9583
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist