Healthcare Provider Details

I. General information

NPI: 1104017573
Provider Name (Legal Business Name): KERI S. H. WARDWELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KERI SHARONA HYATT

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25825 VERMONT AVE
HARBOR CITY CA
90710-3518
US

IV. Provider business mailing address

1499 W 1ST ST
SAN PEDRO CA
90732-3255
US

V. Phone/Fax

Practice location:
  • Phone: 310-517-4083
  • Fax:
Mailing address:
  • Phone: 310-831-9482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA106345
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: