Healthcare Provider Details

I. General information

NPI: 1881803609
Provider Name (Legal Business Name): GIDGET MARIE WOOD NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E ALOSTA AVE
AZUSA CA
91702-2701
US

IV. Provider business mailing address

403 N BENDER AVE
GLENDORA CA
91741-2545
US

V. Phone/Fax

Practice location:
  • Phone: 626-815-2100
  • Fax: 626-815-2102
Mailing address:
  • Phone: 626-963-3992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP15146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: