Healthcare Provider Details

I. General information

NPI: 1306141379
Provider Name (Legal Business Name): AMANDA E WARDLEIGH IDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MEDICAL BATTALION
CAMP PENDLETON CA
92055-5657
US

IV. Provider business mailing address

5426 ROCKING HORSE LN
OCEANSIDE CA
92057-5512
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-2276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: