Healthcare Provider Details

I. General information

NPI: 1013071836
Provider Name (Legal Business Name): WENDY E WEISS LIC. AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9667 HWY 29 SUITE 202
LOWER LAKE CA
95457-4804
US

IV. Provider business mailing address

PO BOX 105
LOWER LAKE CA
95457-0105
US

V. Phone/Fax

Practice location:
  • Phone: 707-277-0891
  • Fax: 707-277-0891
Mailing address:
  • Phone: 707-277-0891
  • Fax: 707-277-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number4208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: