Healthcare Provider Details

I. General information

NPI: 1407625643
Provider Name (Legal Business Name): WENDY JOHANNA COLOCHO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2023
Last Update Date: 04/19/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45604 17TH ST W
LANCASTER CA
93534-5194
US

IV. Provider business mailing address

45604 17TH ST W
LANCASTER CA
93534-5194
US

V. Phone/Fax

Practice location:
  • Phone: 661-874-6347
  • Fax: 201-331-5003
Mailing address:
  • Phone: 661-533-5088
  • Fax: 201-331-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95080528
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95029221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: