Healthcare Provider Details

I. General information

NPI: 1831038991
Provider Name (Legal Business Name): LILY JANE WISTAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38420 VIEW DR
CHERRY VALLEY CA
92223-4149
US

IV. Provider business mailing address

38420 VIEW DR
CHERRY VALLEY CA
92223-4149
US

V. Phone/Fax

Practice location:
  • Phone: 909-801-0700
  • Fax: 909-801-0700
Mailing address:
  • Phone: 909-801-0700
  • Fax: 909-801-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: