Healthcare Provider Details

I. General information

NPI: 1558964007
Provider Name (Legal Business Name): MALORIE ANNE WAGMAN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 WILSHIRE BLVD STE 309
LOS ANGELES CA
90048-5723
US

IV. Provider business mailing address

6333 WILSHIRE BLVD STE 309
LOS ANGELES CA
90048-5723
US

V. Phone/Fax

Practice location:
  • Phone: 323-651-5107
  • Fax:
Mailing address:
  • Phone: 323-651-5107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU4004
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number10864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: