Healthcare Provider Details

I. General information

NPI: 1801244389
Provider Name (Legal Business Name): COLLEEN WENDTLAND CPED, CFOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 PEPPER LN
BANNING CA
92220-1469
US

IV. Provider business mailing address

1468 PEPPER LN
BANNING CA
92220-1469
US

V. Phone/Fax

Practice location:
  • Phone: 909-553-0646
  • Fax:
Mailing address:
  • Phone: 909-553-0646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: