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NPI Code Detail

MEDICARE: LA QUANDA WILSON

MEDICARE: LA QUANDA WILSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1073914198
Entity Type Code : Individual
Provider Name (Legal Business Name) : LA QUANDA WILSON
Provider Business Mailing Address
First Line : 9564 MAIE AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90002-2349
Country : US
Telephone Number : 310-597-3779
Fax Number :
Provider Business Practice Location Address
First Line : 4300 LONG BEACH BLVD STE 700
Second Line :
City : LONG BEACH
State : CA
Zip : 90807-2000
Country : US
Telephone Number : 310-783-4677
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/08/2014
Last Update Date : 09/08/2014

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Directions to “ LA QUANDA WILSON ” Practice Location

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