Healthcare Provider Details

I. General information

NPI: 1487532255
Provider Name (Legal Business Name): SOPHIA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 BEACH BLVD STE 25
BUENA PARK CA
90621-2840
US

IV. Provider business mailing address

6301 BEACH BLVD STE 245
BUENA PARK CA
90621-4031
US

V. Phone/Fax

Practice location:
  • Phone: 714-736-0231
  • Fax:
Mailing address:
  • Phone: 714-736-0231
  • Fax: 714-736-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: